Healthy Eating & Eating Disorders - Anorexia, Bulimia, Binging

00:00:00.320 | - Welcome to the Huberman Lab Podcast,

00:00:02.280 | where we discuss science and science-based tools

00:00:04.880 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.260 | and I'm a professor of neurobiology and ophthalmology

00:00:12.940 | at Stanford School of Medicine.

00:00:15.160 | Today, we are going to talk all about healthy

00:00:17.520 | and disordered eating.

00:00:19.240 | And indeed, we are going to talk

00:00:20.480 | about clinical eating disorders,

00:00:22.480 | such as anorexia, bulimia, and binge eating disorder,

00:00:27.100 | as well as some other related eating disorders.

00:00:30.280 | However, before we get into this material,

00:00:32.360 | I want to emphasize that today's discussion will include

00:00:35.920 | what it is to have a healthy relationship with food.

00:00:39.320 | We're going to talk about metabolism.

00:00:41.560 | We're going to talk about how eating frequency

00:00:44.400 | and what one eats influences things like appetite

00:00:48.680 | and satiety, as well as whether or not we have

00:00:51.840 | a healthy psychological relationship to food

00:00:54.680 | and our body weight and so-called body composition,

00:00:58.520 | the ratio of muscle to fat to bone, et cetera.

00:01:01.760 | So as we march into this conversation,

00:01:05.040 | I'd like to share with you some interesting

00:01:07.160 | and what I believe are important findings

00:01:09.080 | in the realm of nutrition and human behavior.

00:01:13.120 | I know these days, many people are excited about

00:01:16.120 | or curious about so-called intermittent fasting.

00:01:19.700 | Intermittent fasting is, as the name implies,

00:01:22.720 | simply restricting one's feeding behavior,

00:01:25.940 | eating to a particular phase of the 24 hour

00:01:29.360 | or so-called circadian cycle.

00:01:32.200 | Other forms of intermittent fasting involve

00:01:34.520 | not eating for extended periods of time,

00:01:37.240 | for an entire days, or some people will extend

00:01:39.360 | to two days or three days, typically,

00:01:42.040 | and hopefully they will drink water during those times,

00:01:45.580 | sometimes referred to as water fasting,

00:01:48.280 | which means that they are ingesting fluids

00:01:51.200 | and hopefully they are ingesting electrolytes

00:01:53.160 | such as salt, potassium, and magnesium as well,

00:01:56.000 | because while one can survive for some period of time

00:02:00.480 | without ingesting calories, it is extremely important

00:02:03.860 | to continue to ingest plenty of fluids and electrolytes.

00:02:08.000 | And the reason for that is that the neurons

00:02:10.380 | of your brain and body that control your movements,

00:02:12.560 | your thoughts, clarity of thinking in general, et cetera,

00:02:15.940 | is critically dependent on the presence

00:02:19.140 | of adequate levels of sodium, potassium, and magnesium,

00:02:23.080 | the electrolytes, and that's because neurons

00:02:25.300 | can only be electrically active by way of movement

00:02:28.140 | of particular ions, which include things like sodium,

00:02:30.820 | potassium, and magnesium.

00:02:32.320 | So without those, you can't think, you can't function,

00:02:35.660 | and it actually can be quite dangerous.

00:02:37.600 | So why all the excitement about intermittent fasting?

00:02:40.860 | Well, a lot of the excitement relates to work

00:02:43.700 | that was done by a former colleague of mine

00:02:45.700 | down at the Salk Institute for Biological Studies

00:02:47.900 | in San Diego named Sachin Panda.

00:02:50.460 | Sachin's lab identified some very important

00:02:54.040 | and impactful health benefits

00:02:56.220 | of restricting one's feeding window to particular times

00:02:59.200 | within the 24-hour cycle, or even to having extended fasts

00:03:04.020 | that go for a day or two days, or maybe even three days.

00:03:06.980 | What they saw was an improvement in liver enzymes,

00:03:11.700 | an improvement in insulin sensitivity,

00:03:14.880 | which is something that is good.

00:03:16.420 | It means that you can utilize the calories

00:03:19.120 | and the blood sugar that you happen to have.

00:03:22.120 | Being insulin-insensitive is not good

00:03:24.980 | and is actually a form of diabetes.

00:03:27.280 | What Sachin's lab and subsequently other labs showed

00:03:32.040 | was that restricting one's feeding window

00:03:34.100 | to anywhere from four to eight or even 12 hours

00:03:37.860 | during each 24-hour cycle was beneficial in mice.

00:03:41.440 | And some studies in humans have also shown

00:03:43.660 | that it can be beneficial for various health parameters.

00:03:47.200 | However, the excitement about intermittent fasting

00:03:51.060 | seems to be related to the foundational truth

00:03:54.980 | about metabolism and weight loss and weight maintenance

00:03:59.260 | and weight gain, which is that regardless of whether or not

00:04:03.360 | you intermittent fast or whether or not you eat small meals

00:04:06.300 | all day long, or you eat one meal in the evening

00:04:09.140 | and snack up until then, it really doesn't matter

00:04:13.380 | in the sense that the calories that you ingest

00:04:17.020 | from whatever source are going to be filtered

00:04:21.040 | through the calories that you burn by way of exercise,

00:04:25.220 | basal metabolic rate, which is just the calories

00:04:27.460 | that you happen to burn, just being alive and thinking

00:04:30.360 | and breathing and your heart beating, et cetera.

00:04:32.700 | And the reason why many people prefer intermittent fasting

00:04:36.720 | to other forms of, let's just call it what it is,

00:04:39.740 | diet or nutritional framework is that many people

00:04:44.140 | find it easier to not eat than to limit their portion size.

00:04:49.020 | And here I'm not talking necessarily about eating disorders,

00:04:51.900 | I'm talking about the general population.

00:04:53.880 | So I think that's one reason why there's so much excitement

00:04:56.500 | about intermittent fasting.

00:04:58.460 | Now, within the context of intermittent fasting

00:05:01.620 | on a circadian timescale once every 24 hours,

00:05:04.880 | you generally find two categories of people.

00:05:08.420 | People who prefer to not eat in the morning,

00:05:10.940 | either because they are not hungry in the morning

00:05:13.040 | or because they find it relatively straightforward

00:05:15.780 | to just drink things like coffee or water, et cetera,

00:05:20.020 | and push their feeding window out to noon or 2 p.m.

00:05:24.120 | or 3 p.m., and then they'll eat between say 1 p.m.

00:05:26.600 | and 8 p.m. or 9 p.m., it depends on the individual.

00:05:30.140 | Other groups of people find that they are very hungry

00:05:33.500 | when they wake up in the morning,

00:05:34.820 | they don't feel well if they don't eat breakfast.

00:05:37.060 | And so they prefer to eat early in the day,

00:05:39.380 | but then they limit their feeding window

00:05:40.860 | such that they cut off their food intake

00:05:42.720 | or stop ingesting any calories of any kind

00:05:45.420 | somewhere around 5 p.m. or 6 p.m., et cetera.

00:05:49.260 | So the duration of the feeding window

00:05:51.020 | has not been broken down

00:05:52.900 | into the kind of nuanced type of information

00:05:55.460 | that one would really want,

00:05:56.940 | at least not in human studies,

00:05:58.060 | saying, well, a six-hour feeding window

00:05:59.980 | or an eight-hour feeding window is ideal.

00:06:02.200 | It really is going to vary

00:06:03.280 | based on lifestyle and circumstances.

00:06:05.100 | For instance, some families

00:06:07.020 | really want to eat dinner together every night.

00:06:09.320 | So do you want to be the person

00:06:10.780 | that's sitting there watching everybody eat

00:06:12.400 | because you're fasting from 5 p.m. onward?

00:06:15.420 | I don't know, that's an individual difference.

00:06:17.660 | What you can start to identify, however,

00:06:19.580 | is that people tend to fall

00:06:20.700 | into either one category or the other,

00:06:22.260 | people who prefer to skip eating in the morning

00:06:24.480 | or people that prefer to

00:06:26.140 | or manage to skip eating in the evening.

00:06:28.180 | And there has been no evidence thus far

00:06:31.240 | that one is better or worse,

00:06:32.780 | at least in terms of weight loss or overall health parameters.

00:06:36.440 | Now, you could imagine

00:06:37.900 | that some people might eat breakfast and dinner.

00:06:39.720 | And indeed, I have several, many colleagues, in fact,

00:06:42.460 | who just choose to skip lunch

00:06:43.800 | because they're busy during the day.

00:06:44.780 | They eat breakfast and dinner.

00:06:46.480 | That doesn't afford the long fast associated with sleep.

00:06:51.060 | What do I mean by that?

00:06:51.900 | Well, if you went to sleep at 11 p.m.

00:06:53.760 | and you wake up at 6 a.m.

00:06:55.840 | by extending your fast until 1 p.m. in the afternoon,

00:06:59.220 | you get quite a long period of no ingesting any calories.

00:07:02.840 | Whereas when you don't eat during the middle of the day,

00:07:05.660 | you are getting a fasting period

00:07:07.180 | that's probably anywhere from four to seven hours,

00:07:10.340 | but it's not linked to the longer fasting period

00:07:13.260 | of not eating while you are asleep.

00:07:15.400 | Because most all people, and I want to emphasize most,

00:07:18.100 | do not eat while they are asleep.

00:07:20.180 | But we are going to talk about an eating disorder

00:07:22.380 | that does exist where people actually eat in their sleep.

00:07:26.180 | I know it sounds pretty wild,

00:07:27.600 | but indeed that eating disorder does exist

00:07:31.640 | and has a very interesting underlying mechanism.

00:07:35.120 | So why are we talking about this?

00:07:36.620 | And in particular, why are we talking about this

00:07:39.560 | during an episode that includes a discussion

00:07:41.700 | about eating disorders?

00:07:43.620 | The reason is nobody, not the government,

00:07:47.160 | no nutritionists, no individual,

00:07:50.720 | no matter how knowledgeable they are

00:07:52.480 | about food and nutrition and food intake

00:07:55.280 | can define the best plan for eating for any one individual.

00:08:00.280 | I'm going to repeat that.

00:08:02.020 | Nobody knows what truly healthy eating is.

00:08:05.460 | We only know the measurements we can take.

00:08:07.820 | Liver enzymes, blood, lipid profiles, body weight,

00:08:11.940 | athletic performance, mental performance,

00:08:14.700 | whether or not you're cranky all day,

00:08:16.100 | whether or not you're feeling relaxed,

00:08:17.880 | nobody knows how to define these.

00:08:19.380 | And these have strong cultural and familial

00:08:23.680 | and socio societal influence.

00:08:27.180 | So if you hang out with people

00:08:28.380 | that intermittent fast all day, that will seem normal.

00:08:31.420 | If you spend time with people

00:08:32.860 | that have never heard of intermittent fasting,

00:08:34.620 | intermittent fasting is going to seem very abnormal.

00:08:37.780 | Now we are going to talk about eating disorders

00:08:39.760 | that really fall into the category

00:08:41.360 | of clinically diagnosable eating disorders

00:08:44.500 | for which there's actually serious health hazards

00:08:47.580 | and even the serious risk of death.

00:08:49.820 | We will get to that topic.

00:08:51.420 | But for the time being,

00:08:53.640 | I want to emphasize a new set of findings

00:08:56.660 | that I think many people will find interesting

00:08:58.400 | and at least will want to consider

00:09:00.200 | in light of their current nutritional plan

00:09:02.540 | or pattern of eating,

00:09:04.300 | whether or not you're intermittent fasting or not.

00:09:06.840 | And I want to cue up an important framework

00:09:09.640 | for the rest of the conversation

00:09:11.020 | on healthy and disordered eating,

00:09:13.020 | which includes an understanding of thinking,

00:09:17.640 | decision-making and what we call homeostatic processes,

00:09:21.680 | meaning regulation of things

00:09:23.260 | that are going on in our brain and body

00:09:24.820 | and reward mechanisms.

00:09:26.180 | I'm going to return to that in a moment.

00:09:28.100 | But first I want to share with you these new findings

00:09:30.640 | that were just published in the journal Cell Reports,

00:09:32.800 | a cell press journal, excellent journal.

00:09:35.020 | This was a study that was performed both in mice

00:09:37.900 | and it included a crossover study with a human population.

00:09:41.500 | The human population was women,

00:09:44.580 | but it relates to a previous study

00:09:46.620 | that was also carried out in men.

00:09:48.600 | I'm going to simplify this study.

00:09:49.820 | We will provide a link to the full study

00:09:51.620 | so you can explore it in more detail.

00:09:53.320 | And if you're really excited about the results,

00:09:55.160 | I would encourage you to explore some of the references

00:09:58.120 | within that paper as well.

00:10:00.500 | What was the study?

00:10:02.760 | The study looked at giving mice or humans two meals

00:10:07.760 | and explored whether or not putting those meals

00:10:10.800 | early in the day or late in the day

00:10:14.360 | had an impact on muscle hypertrophy, muscle growth,

00:10:18.760 | and overall protein synthesis of muscle.

00:10:21.400 | So when we eat, the amino acids from various foods

00:10:24.820 | are broken down and synthesized

00:10:26.360 | into different types of tissues.

00:10:27.600 | They can be utilized for energy,

00:10:30.080 | burned up for moving about and thinking, et cetera,

00:10:32.680 | or those amino acids can be synthesized

00:10:36.040 | into skeletal muscle, the sorts of skill to muscles

00:10:39.060 | that allow you to move your limbs.

00:10:42.740 | This study explored how protein intake,

00:10:46.540 | which included what are called branch chain amino acids

00:10:50.500 | and amino acids like leucine,

00:10:52.220 | which are important for muscle protein synthesis.

00:10:54.360 | It explored whether or not emphasizing

00:10:57.880 | or skewing the protein intake toward early day or late day

00:11:02.880 | was better in terms of muscle hypertrophy.

00:11:06.880 | And they also looked at some parameters of strength

00:11:08.940 | like grip strength.

00:11:10.820 | Now, mice are nocturnal.

00:11:12.920 | So before you say, wait, mice are nocturnal,

00:11:14.760 | how did they look during the day?

00:11:15.840 | And it's completely, it doesn't apply 'cause it's in mice.

00:11:18.360 | Of course, they knew that.

00:11:20.260 | And they looked during the mice's active phase

00:11:24.280 | of their circadian cycle, which corresponds to our day.

00:11:26.840 | And in humans, they looked at whether or not

00:11:28.800 | eating most of one's protein early in the day

00:11:32.440 | was better than if the protein intake

00:11:34.420 | and these branch chain amino acids

00:11:36.180 | were placed later in the day.

00:11:38.160 | And yes, they had the mice do resistance training.

00:11:41.200 | They did that by emphasizing overload

00:11:44.360 | to one limb of the mouse.

00:11:46.960 | And that actually generates hypertrophy.

00:11:48.520 | It's a form of resistance training in mice.

00:11:50.940 | So they don't have them weight training.

00:11:52.480 | They weren't doing curls and dips and squats

00:11:55.000 | and things of that sort.

00:11:55.960 | They were moving their own body weight,

00:11:57.320 | but they skewed that distribution of body weight

00:11:59.660 | by restricting a limb and forcing them to use one limb

00:12:03.120 | that did indeed grow in response to that.

00:12:05.480 | And then in humans, there was an exploration of grip strength

00:12:08.400 | and then with resistance training,

00:12:10.160 | that was also carried out through a peripheral study.

00:12:13.460 | Basically, the takeaway from this study

00:12:15.840 | was that mice and humans can utilize amino acids

00:12:20.840 | that are ingested early in the day

00:12:22.940 | better than they can utilize amino acids

00:12:25.360 | ingested later in the day.

00:12:27.240 | In particular, toward muscle hypertrophy and growth

00:12:31.960 | or maintenance of muscle,

00:12:34.360 | which for those of you that aren't interested

00:12:36.180 | in much muscle hypertrophy,

00:12:37.480 | that aren't trying to grow your muscles,

00:12:39.020 | I've talked before in the episode

00:12:40.640 | on building strength and hypertrophy,

00:12:43.360 | that maintaining muscle,

00:12:45.580 | regardless of one's athletic prowess,

00:12:47.840 | regardless of one's age is extremely important

00:12:50.400 | because loss of skeletal muscle

00:12:53.240 | is one of the major causes of injury as we age.

00:12:55.960 | It's one of the major causes, believe it or not,

00:12:58.480 | of cognitive and metabolic deficits as we age.

00:13:03.160 | So maintaining muscle is important,

00:13:04.800 | building muscle might be important to some of you,

00:13:06.600 | but what they found was ingesting protein early in the day

00:13:10.320 | and these amino acids early in the day

00:13:12.800 | led to more muscle hypertrophy

00:13:14.480 | than if the majority of amino acids and proteins

00:13:16.880 | were ingested late in the day.

00:13:18.480 | So this translates to intermittent fasting

00:13:21.220 | such that if you are interested in muscle hypertrophy,

00:13:23.840 | you might, and I want to emphasize might,

00:13:25.720 | consider making sure that you're getting

00:13:28.560 | sufficient protein intake early in the day.

00:13:31.600 | What sources of protein you use

00:13:33.080 | is going to be highly individual.

00:13:34.360 | Some of you are meat eaters,

00:13:35.680 | some of you don't eat red meat,

00:13:37.120 | some of you eat chicken and fish and eggs,

00:13:38.980 | some of you don't, some of you are vegans.

00:13:40.920 | It has been shown that the amino acid leucine

00:13:43.480 | is vital for the cell growth process,

00:13:46.000 | including muscle growth because of its relationship

00:13:48.380 | to the so-called mTOR pathway,

00:13:50.000 | mammalian target of rapamycin.

00:13:52.240 | We can talk about that more if you like

00:13:54.160 | in a future episode.

00:13:56.340 | This means that if you're somebody who wants to maintain

00:13:59.080 | or increase the amount of muscle mass that you have,

00:14:02.440 | ingesting a high protein meal early in the day

00:14:05.680 | ought to be beneficial for that.

00:14:07.900 | Does it mean that you should not eat protein

00:14:09.960 | in the afternoon and evening?

00:14:11.960 | No, I think a lot of people might have misinterpreted

00:14:15.180 | this study and I don't want that to happen.

00:14:17.880 | This is only pointing out the fact

00:14:19.880 | that ingesting sufficient quality amino acids,

00:14:23.280 | including leucine, early in the day

00:14:26.600 | can be beneficial for maintenance

00:14:29.360 | and growth of muscle tissue.

00:14:30.880 | It does not say that you should avoid protein

00:14:33.680 | later in the day.

00:14:35.000 | Now for you intermittent fasters, this could be relevant.

00:14:38.500 | I, for instance, was somebody who for a very long time

00:14:41.460 | skipped breakfast.

00:14:42.600 | My first meal of the day would be in the early afternoon,

00:14:45.240 | mostly protein and salad.

00:14:47.560 | In my case, animal protein,

00:14:48.840 | 'cause that's in alignment with my values.

00:14:51.760 | Then in the evening I would eat pasta, vegetables, et cetera.

00:14:55.400 | I might have some protein, some small piece of fish

00:14:57.360 | or chicken or something like that,

00:14:58.360 | but I didn't really emphasize that.

00:15:00.660 | On the basis of these results, I am experimenting with,

00:15:03.560 | I want to emphasize, experimenting with,

00:15:05.160 | I haven't completely tossed out my old protocol,

00:15:08.740 | but I'm experimenting with eating proteins early in the day

00:15:12.700 | and eating lunch and then dinner might be a light supper

00:15:16.800 | of some sort, but not so much protein later in the evening.

00:15:20.500 | Again, if you want to eat six meals a day,

00:15:22.200 | you want to eat around the clock, I'm not going to stop you.

00:15:24.140 | I'm not telling anybody what to do.

00:15:25.420 | As I mentioned earlier, nobody knows exactly how to eat

00:15:28.000 | for one's particular goals,

00:15:29.320 | but this study was really interesting

00:15:30.800 | because it really did show that we can utilize the proteins

00:15:34.140 | that are ingested early in the day better

00:15:36.460 | than we can utilize the proteins

00:15:37.720 | that are ingested later in the day.

00:15:39.360 | And of course, there will be factors that can shift that.

00:15:42.860 | For instance, if you work out very hard

00:15:44.520 | with resistance training later in the day,

00:15:46.400 | resistance training is known to increase protein synthesis.

00:15:49.820 | So it stands to reason that ingesting amino acids

00:15:52.640 | after that training would be beneficial.

00:15:54.760 | However, in the study, it did not seem to matter

00:15:57.340 | when the resistance training fell

00:15:58.860 | within the 24 hour schedule.

00:16:00.480 | The morning ingestion or early day ingestion of amino acids

00:16:05.120 | seemed to be beneficial.

00:16:06.400 | How early?

00:16:07.240 | Between the hours of about 5 a.m. and 10 a.m. for humans.

00:16:11.640 | Now, just a bit of mechanism to explain why this happens.

00:16:15.860 | So why would it be that ingesting protein early in the day

00:16:18.920 | would lead to more synthesis of muscle

00:16:21.120 | than ingesting protein later in the day?

00:16:23.400 | And the reason it turns out

00:16:25.160 | is related to the circadian clock mechanism

00:16:27.920 | that is present in all cells, including muscle cells.

00:16:30.840 | So muscles have fibers.

00:16:32.060 | I think most people are aware of that,

00:16:33.380 | that your muscles are not just one big blob of tissue.

00:16:36.040 | A lot of these little fibers that contract.

00:16:38.480 | Within those fibers, however, there are cells with nuclei.

00:16:44.080 | Those nuclei contain DNA.

00:16:46.720 | DNA is transcribed into RNA.

00:16:48.640 | RNA is translated into proteins.

00:16:51.400 | The DNA of your cells, including these muscle cells,

00:16:55.800 | are under strong circadian regulation.

00:16:58.880 | Each one has a pattern of gene expression

00:17:01.600 | that is different at different times

00:17:03.500 | during the 24 hour cycle.

00:17:05.020 | This is an unescapable reality of all cells in your body,

00:17:09.960 | right from your hair cells to your brain cells,

00:17:12.140 | to your retinal cells, to your toe on both feet.

00:17:16.200 | These cells make a gene called BMAL, BMAL, B-M-A-L,

00:17:20.940 | is a clock gene.

00:17:22.160 | And the expression of this clock gene

00:17:24.080 | varies across the 24 hour cycle.

00:17:26.400 | And proteins that are downstream of this BMAL gene

00:17:29.800 | influence protein synthesis.

00:17:31.520 | The circadian regulation of this BMAL gene

00:17:35.440 | turns out to be vitally important

00:17:37.220 | for this protein synthesis mechanism.

00:17:40.200 | How do we know that?

00:17:41.060 | Well, in this particular study,

00:17:42.640 | because they had a mouse that lacked BMAL,

00:17:47.160 | the gene was knocked out.

00:17:48.760 | They had a bunch of these mice.

00:17:50.800 | They were able to explore

00:17:52.000 | whether or not this early day feeding effect

00:17:54.960 | was present or absent in these mice

00:17:57.440 | that lack the gene BMAL, and indeed it was absent.

00:18:00.540 | In other words, the effect of increased protein synthesis

00:18:03.600 | early in the day was eliminated

00:18:05.240 | in the absence of the BMAL gene.

00:18:07.140 | So what this means is that when you wake up in the morning,

00:18:10.760 | assuming you're following a standard schedule

00:18:12.760 | of being asleep at night and awake during the day,

00:18:15.600 | your muscle cells are primed to incorporate amino acids

00:18:19.040 | and synthesize muscle,

00:18:20.640 | regardless of whether or not you wait-trained

00:18:22.360 | the night before at 8 p.m.,

00:18:24.080 | where you don't wait-train at all,

00:18:25.260 | or you wait-train afterwards or before.

00:18:27.220 | I said 5 to 10 p.m. is the sort of critical window

00:18:31.840 | for this increased protein synthesis.

00:18:33.720 | All this means is that if you are interested in maintaining

00:18:36.600 | or enhancing muscle tissue volume,

00:18:40.080 | that you might want to consider eating quality protein

00:18:44.840 | and amino acids early in the day.

00:18:47.280 | You could train first, you could train after,

00:18:49.700 | you could not train at all.

00:18:51.100 | That's an entirely different discussion.

00:18:53.180 | What is quality protein?

00:18:55.720 | Well, quality protein is going to be a protein

00:18:57.640 | that includes most of the essential amino acids

00:19:00.420 | and in particular, leucine.

00:19:01.780 | Now, there's a lot of debate as to whether or not

00:19:04.920 | you can get all the essential amino acids

00:19:07.160 | from a purely plant-based diet

00:19:08.640 | or whether or not you need to ingest

00:19:10.160 | animal-based foods or not.

00:19:12.360 | The term quality protein has no strict scientific definition.

00:19:17.160 | Some people define quality protein as a protein

00:19:20.280 | that has a high essential amino acid to caloric ratio.

00:19:24.840 | Now, what that means is a small piece of chicken or steak

00:19:28.500 | or eggs, for instance, will have many essential amino acids

00:19:32.660 | with a low caloric content relative to, say,

00:19:37.360 | beans or plant-based foods

00:19:39.520 | that can also get you essential amino acids,

00:19:41.760 | but it requires more calories

00:19:43.360 | to access those essential amino acids.

00:19:47.080 | Now, that's a debate that has many exceptions and nuances.

00:19:50.440 | And I, for one, am perfectly respectful of the folks

00:19:53.300 | that just want to ingest plant-based foods

00:19:55.960 | in order to get their high quality protein.

00:19:57.880 | I think that actually can be done.

00:19:59.800 | One has to be careful and thoughtful in their choices

00:20:02.580 | about how to do that.

00:20:03.620 | So this really isn't about animal-based

00:20:05.660 | versus non-animal-based foods.

00:20:07.420 | This is about getting quality amino acids early in the day

00:20:11.240 | from whatever foods are in alignment

00:20:14.140 | with your particular values in your particular eating plan.

00:20:16.580 | So that's a lot of information,

00:20:18.620 | but the key takeaways are every cell in your muscles

00:20:21.920 | has a clock gene.

00:20:23.320 | The clock genes vary such that protein synthesis

00:20:27.180 | is greater early in the day than it is later in the day,

00:20:30.420 | such that in both mice and in humans,

00:20:33.340 | ingestion of quality proteins early in the day

00:20:36.500 | will be more so incorporated into muscle

00:20:39.660 | than the proteins that are ingested late in the day.

00:20:42.300 | And of course, there are the caveats

00:20:44.260 | of if you're training hard late in the day,

00:20:47.640 | if you're adjusting your hormone status

00:20:49.540 | through whatever mechanism, et cetera,

00:20:52.060 | protein synthesis can also be high later in the day.

00:20:54.920 | But for most people, it's going to taper off

00:20:56.660 | due to this circadian B-mal gene-related mechanism.

00:21:00.460 | Again, we will provide a link to the study.

00:21:02.780 | And the other key takeaways were that nobody knows,

00:21:06.140 | nobody can tell you what healthy feeding windows are,

00:21:09.220 | what the best feeding windows are.

00:21:10.720 | There's absolutely no information in that context.

00:21:13.220 | You talk to 10 nutritionists or academics or trainers

00:21:18.220 | or individuals about what healthy eating is,

00:21:20.620 | and you are going to get vastly different answers.

00:21:22.900 | And that's one of the reasons why I believe that

00:21:25.820 | the internet, in particular social media,

00:21:28.060 | are so filled with contradictory opinions.

00:21:30.780 | But the calories in versus calories burned formula

00:21:35.620 | is the more or less holy foundation

00:21:38.580 | of all things about nutrition, eating, and weight.

00:21:41.420 | And as we transition today into the discussion

00:21:43.540 | about eating disorders, I'd like you to keep this in mind

00:21:47.060 | because for the treatment of eating disorders,

00:21:49.600 | it doesn't matter what psychological

00:21:52.720 | or early trauma-based effects led to the eating disorder

00:21:56.560 | if the person isn't adjusting their feeding behavior

00:21:59.540 | in a way that is going to ameliorate the symptoms

00:22:02.020 | of that disorder, which is ultimately the goal.

00:22:04.860 | Before we begin, I'd like to emphasize that this podcast

00:22:07.400 | is separate from my teaching and research roles at Stanford.

00:22:10.320 | It is, however, part of my desire and effort

00:22:12.500 | to bring zero cost to consumer information about science

00:22:15.180 | and science-related tools to the general public.

00:22:18.120 | In keeping with that theme,

00:22:19.180 | I'd like to thank the sponsors of today's podcast.

00:22:22.160 | Our first sponsor is Belcampo.

00:22:24.700 | Belcampo is a regenerative farm in Northern California

00:22:27.440 | that raises organic, grass-fed, and finished

00:22:30.260 | certified humane meats.

00:22:32.460 | I don't eat a lot of meat, but I eat meat about once a day.

00:22:36.200 | That means a small piece of steak or chicken, et cetera,

00:22:39.420 | and usually a salad.

00:22:40.900 | I usually do that for breakfast or for lunch.

00:22:43.900 | And then in the evening,

00:22:44.820 | I tend to follow a more or less vegetarian diet.

00:22:47.380 | I tend to eat pastas and vegetables and things of that sort.

00:22:50.380 | While I don't eat a lot of meat,

00:22:53.120 | it's important that the meat that I eat

00:22:54.460 | be of very high quality and that I am certain

00:22:57.100 | that the animals were raised and treated humanely

00:22:59.760 | up until the point of slaughter.

00:23:02.060 | Belcampo's animals graze on open pastures

00:23:04.120 | and seasonal grasses their entire lives,

00:23:06.160 | resulting in meat that's higher in nutrients

00:23:07.780 | and healthy fats.

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00:23:11.620 | I often talk about how important omega-3 fatty acids are.

00:23:16.020 | They've been shown to be important for regulating mood,

00:23:18.800 | for the microbiome, for restricting inflammation in the brain

00:23:21.900 | and elsewhere in the body.

00:23:23.280 | Belcampo's meats are known to be high in omega-3s.

00:23:26.080 | And given that the meat is grass fed and grass finished,

00:23:29.340 | that combines all the features of the nutrition

00:23:32.740 | and the animal wellbeing that I want to see

00:23:35.540 | for any meat that I ingest.

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00:23:39.180 | first-time customers can get 20% off

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00:23:50.580 | Today's podcast is also brought to us by Headspace.

00:23:53.580 | Headspace is a meditation app that's backed by 25

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00:24:01.160 | I've been meditating for a very long time,

00:24:03.680 | although I admit I meditate on and off,

00:24:05.940 | meaning I'll go a few weeks or months,

00:24:07.880 | meditating regularly, and then I tend to stop.

00:24:10.960 | A few years ago, I got into a regular meditation practice

00:24:13.920 | because I started using Headspace's meditation app.

00:24:17.280 | The thing I really like about their meditation app

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00:24:59.060 | Today's episode is also brought to us by Athletic Greens.

00:25:01.900 | Athletic Greens is a vitamin mineral probiotic drink,

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00:26:29.640 | So let's talk about eating disorders.

00:26:31.860 | And as we do that, I want to emphasize again

00:26:34.100 | that nobody can really define what healthy eating is

00:26:37.360 | with a single protocol.

00:26:38.620 | However, there is some general agreement

00:26:40.320 | about what unhealthy and disordered eating is.

00:26:44.320 | There are clear criteria in the psychiatric

00:26:46.780 | and psychological communities to define things

00:26:50.000 | like anorexia, bulimia, binge eating disorder,

00:26:53.040 | all of which we will talk about.

00:26:54.780 | But as we have that discussion,

00:26:55.980 | I want to emphasize that self-diagnosis

00:26:59.540 | can be both a terrific, but also a very precarious thing.

00:27:03.900 | We talked about this a little bit

00:27:05.060 | in the episode about depression.

00:27:07.060 | There's always a temptation as one learns

00:27:09.540 | about the symptomology of a given disorder,

00:27:11.780 | doesn't really matter what the disorder is,

00:27:14.140 | to ask the question, well, do I have that?

00:27:16.180 | Does so-and-so that I know have that,

00:27:17.900 | ah, I see this sort of behavior

00:27:19.740 | or that pattern of thinking in that individual?

00:27:23.220 | It's tempting to diagnose them and or ourselves

00:27:26.140 | as either having or not having a particular disorder.

00:27:28.460 | However, diagnoses really need to be carried out

00:27:32.920 | by people who are trained in that particular field

00:27:36.320 | and that have deep expertise in recognizing the symptomology,

00:27:39.780 | including some of the more subtle symptomology

00:27:42.100 | of eating disorders.

00:27:43.340 | So if any of the symptoms resonate with you

00:27:46.600 | by way of you thinking that you have

00:27:49.740 | this particular disorder or someone that you know

00:27:51.780 | has a disorder, I would take that seriously,

00:27:54.940 | but I would take that information

00:27:56.720 | to a qualified healthcare professional

00:27:58.780 | that could diagnose or rule out

00:28:01.500 | any of these possible disorders.

00:28:03.380 | I say that not to protect us, but to protect you,

00:28:06.660 | because information is valuable.

00:28:08.340 | And I do believe that knowledge of knowledge

00:28:10.040 | can be very valuable in navigating any topic

00:28:12.800 | and improving our thoughts and behaviors around that topic.

00:28:15.860 | But one doesn't want to,

00:28:18.120 | or I should say one shouldn't start to self-diagnose

00:28:21.100 | simply on the basis of information

00:28:23.060 | without running that through the filter

00:28:24.940 | of a qualified professional.

00:28:26.720 | So what is an eating disorder?

00:28:28.940 | Well, we have to take a step back

00:28:31.580 | and confess to the fact that every society, every culture,

00:28:35.660 | every family and every individual

00:28:37.660 | has a different relationship to food.

00:28:40.300 | Eating disorders, however, have particular criteria

00:28:43.740 | that allow us to define them

00:28:46.160 | and to think about different modes of treatment

00:28:49.180 | as it relates to the particular symptoms,

00:28:52.880 | in particular the psychological

00:28:54.440 | and biological symptoms of those disorders.

00:28:56.400 | Now that's a mouthful, no pun intended.

00:28:59.080 | What are the major eating disorders?

00:29:00.920 | Anorexia nervosa, most commonly referred to as anorexia,

00:29:06.600 | is perhaps the most prevalent

00:29:09.680 | and the most dangerous of all eating disorders.

00:29:13.100 | In fact, anorexia is the most dangerous

00:29:16.100 | psychiatric disorder of all, even more than depression.

00:29:19.520 | The probability of death for untreated anorexia

00:29:24.620 | is very high.

00:29:26.240 | And sadly, the prevalence of anorexia is very high.

00:29:29.900 | So what is anorexia and how prevalent is it?

00:29:33.500 | Anorexia, if you look it up online

00:29:35.660 | or you talk to a qualified professional,

00:29:37.540 | is essentially a failure to eat enough to maintain

00:29:40.420 | a healthy weight.

00:29:41.440 | You can see all sorts of very troubling symptoms

00:29:45.560 | of somebody who's been anorexic for some period of time.

00:29:48.380 | A general loss of muscle mass

00:29:52.260 | because they're ingesting fewer calories than they burn.

00:29:55.540 | Muscle is very metabolically active.

00:29:57.420 | They tend to lose a lot of muscle mass.

00:29:59.840 | They will have a low heart rate.

00:30:02.020 | This is the body and brain's attempt to lower energy output.

00:30:06.620 | They will have low blood pressure.

00:30:08.240 | They will sometimes have symptoms like fainting.

00:30:10.900 | They will have sometimes even hair growth on the face,

00:30:15.180 | something called lanugo,

00:30:16.820 | which is essentially the body's attempt to insulate the body

00:30:20.580 | because of loss of body heat when you're that thin.

00:30:23.680 | Loss of bone density, osteoporosis,

00:30:28.120 | loss of periods in girls and women,

00:30:31.820 | and all sorts of disrupted gut and immune functions.

00:30:36.820 | So there are just tons of terrible symptoms of anorexia

00:30:40.980 | that really place the anorexic into a very risky state,

00:30:45.700 | which is why mortality from anorexia gone untreated

00:30:49.760 | is extremely high.

00:30:51.780 | Now, one of the misconceptions about anorexia

00:30:55.660 | is that it stems from an overemphasis on perfectionism

00:31:00.060 | or that because of all the images in social media

00:31:04.260 | and in advertising of extremely thin and fit

00:31:07.720 | or muscular people,

00:31:09.220 | that individuals are looking at themselves

00:31:11.740 | and comparing themselves to those images

00:31:14.060 | and thinking that they don't match up

00:31:15.580 | in developing anorexia.

00:31:17.360 | That turns out to not be the case.

00:31:21.100 | If you look at the prevalence or the rates of anorexia

00:31:24.880 | in the last 10 years or 20 years,

00:31:27.220 | and you compare that to when anorexia was first identified,

00:31:30.720 | which was in the 1600s and perhaps even earlier,

00:31:34.100 | what you find is that rates of anorexia are not going up.

00:31:38.500 | So this idea that the images that we're being bombarded with

00:31:41.460 | are causing anorexia doesn't seem to be true.

00:31:45.160 | Now, that is not to say that the images that we,

00:31:48.060 | in particular young people are being bombarded with

00:31:49.940 | are healthy for their psychological state of mind,

00:31:52.940 | but classically defined anorexia has existed

00:31:56.620 | at essentially the same prevalence

00:31:58.380 | for the last 100, 200, 300, and 400 years,

00:32:03.640 | which is incredible and really speaks to the likelihood

00:32:06.540 | that there's a strong biological contribution

00:32:09.420 | to what we call anorexia nervosa.

00:32:12.080 | Anorexia nervosa is extremely common.

00:32:14.820 | It's anywhere from one to 2% of women.

00:32:19.740 | And the typical onset is in adolescents close to puberty,

00:32:24.020 | but it can show up later in life as well.

00:32:26.920 | In fact, the identification and diagnosis of anorexia

00:32:30.860 | tends to be in the early 20s.

00:32:33.420 | But if you look back at the history of those individuals,

00:32:36.520 | there were typically signs of anorexia

00:32:38.840 | that stem back into their early teens

00:32:40.580 | or maybe even before that.

00:32:42.560 | Now, of course, men can be anorexic as well,

00:32:45.400 | but anorexia nervosa does seem to occur

00:32:47.900 | at 10 times the rate in women and young girls

00:32:51.940 | than it does in men and young boys.

00:32:55.060 | So while there does seem to be more of a prevalence

00:32:58.440 | of anorexia in boys and young men these days,

00:33:02.620 | that's probably due to better diagnosis and detection

00:33:06.460 | than it is to some sort of societal shift

00:33:09.620 | related to imagery, et cetera.

00:33:12.040 | Later, we will talk about body dysmorphia

00:33:14.140 | and some of the images that are present in media

00:33:17.500 | and social media and how those are impacting

00:33:19.820 | other forms of eating disorders.

00:33:21.080 | But when you look at anorexia nervosa,

00:33:23.420 | this failure to maintain weight even to healthy levels

00:33:26.320 | and often drops in weight that are very dangerous

00:33:29.160 | or even deadly, that has existed for a very long time

00:33:33.500 | and seems to be somewhat hardwired into the biology

00:33:37.220 | of individuals that suffer from it.

00:33:38.560 | Now, when I say hardwired, that doesn't mean

00:33:40.240 | that it can't be treated or cured and indeed it can.

00:33:43.300 | Bulimia, which is defined as binge eating or overeating,

00:33:48.600 | let me explain what that is.

00:33:49.600 | Binge eating is consuming vast amounts of calories

00:33:52.160 | in a short period of time.

00:33:53.560 | Overeating can be ingesting more calories than one needs,

00:33:58.180 | but over an extended period of time,

00:34:00.360 | both can exist of course, but bulimia is also very common.

00:34:05.040 | It's more common in young girls and in women

00:34:08.480 | that it is in young boys and in men,

00:34:11.260 | but it is present in both sexes.

00:34:13.560 | Bulimia and rates of bulimia might be increasing.

00:34:18.940 | That's sort of an interesting finding.

00:34:21.360 | It's not quite clear whether or not it's existed

00:34:24.280 | in its same form for a long period of time

00:34:26.240 | or whether or not there are new forms

00:34:27.400 | that are evolving or showing up.

00:34:30.760 | We're going to drill into bulimia and what it actually is

00:34:33.920 | and what it represents.

00:34:35.280 | But one thing I want to be clear about,

00:34:37.640 | just as the perfectionist mindset has been associated

00:34:41.240 | with anorexia and it turns out that's not the case.

00:34:45.400 | It can be, but it's not always associated with anorexia.

00:34:49.240 | There was the idea that bulimia is associated

00:34:52.940 | with early trauma in childhood, in particular sexual trauma.

00:34:56.500 | And while that can be the case,

00:34:58.680 | there's no direct correlation between the two.

00:35:01.660 | Now, obviously psychological phenomena and trauma

00:35:05.160 | can have a profound impact on the way

00:35:07.020 | that the brain wires up and the way that people approach food

00:35:10.380 | and other types of behaviors.

00:35:12.440 | But the sort of classic idea was that all anorexics

00:35:16.240 | are perfectionists, they want to perform well,

00:35:18.760 | it's all about control and autonomy.

00:35:20.880 | And bulimics are kind of dysregulated and acting out

00:35:23.720 | against some early sexual trauma.

00:35:25.740 | Those stereotypes of the psychological framework

00:35:29.840 | of anorexics and bulimics doesn't hold up

00:35:33.180 | when you look at the data.

00:35:34.340 | Many meta analyses have been done.

00:35:36.960 | It just simply is not the case.

00:35:38.720 | And in both instances, both anorexia and bulimia,

00:35:42.160 | they're clear biological underpinnings

00:35:44.680 | to what's driving the undereating or the overeating.

00:35:48.260 | So we're going to talk about the biology of undereating

00:35:51.280 | and overeating and appropriate levels of eating.

00:35:54.680 | And by doing that, we will start to identify

00:35:57.000 | some of the mechanisms that serve as entry points

00:36:00.400 | for the treatment of both anorexia and bulimia.

00:36:03.940 | And as some of you are probably aware,

00:36:06.080 | anorexia and bulimia can be comorbid,

00:36:09.600 | they can exist with one another.

00:36:12.100 | There are anorexics who will binge and then purge

00:36:16.140 | in order to maintain that unhealthily low weight.

00:36:19.580 | There are bulimics who fit the psychological criteria

00:36:24.040 | of anorexia.

00:36:25.060 | And so there's a lot of overlap between those two categories.

00:36:28.440 | Now let's talk about the categorization for a second

00:36:30.720 | and why the categorization has led to now

00:36:33.640 | a bunch of other eating disorders

00:36:35.560 | as defined by the psychiatric community.

00:36:38.240 | One of the classic symptoms of anorexia

00:36:40.860 | is a loss of menstrual cycles, loss of periods.

00:36:44.360 | And the reason for that is when the body is undernourished,

00:36:47.580 | the body fat stores send signals to the brain

00:36:52.000 | to inform that the body is undernourished

00:36:54.400 | or they turn off the signals that say,

00:36:57.160 | look, there are enough body fat cells out here

00:36:58.840 | to support healthy metabolism

00:37:01.080 | and therefore let's shut down ovulation.

00:37:04.680 | Literally signal sent from the fat and muscle to the brain

00:37:08.040 | and the brain, the hypothalamus and pituitary will send

00:37:10.960 | signals down to the ovaries or they will turn off

00:37:15.020 | the signals heading to the ovaries to deploy eggs,

00:37:19.100 | maturation of eggs and the follicle, et cetera.

00:37:21.720 | So there are instances in which people have anorexia

00:37:26.720 | or have bulimia,

00:37:27.720 | but are still maintaining healthy menstrual cycles

00:37:30.600 | or at least menstrual cycles.

00:37:31.940 | And that has led to a whole set of other categorizations

00:37:36.860 | of eating disorders, like binge eating disorder,

00:37:38.860 | where there tends to be a lot of overeating,

00:37:41.040 | but not the purging or categorizations of anorexia

00:37:44.840 | where in which people are under feeding,

00:37:47.060 | but they are not losing their periods.

00:37:48.960 | And so these have a number of different names and acronyms.

00:37:51.760 | Some of them include things like EDNOS.

00:37:54.440 | EDNOS is eating disorder, not otherwise specified.

00:37:58.960 | So that's a sub-categorization or OSFEDS.

00:38:02.160 | So OSFEDS is other specified feeding or eating disorder.

00:38:06.400 | So right now, if you were to look online

00:38:08.740 | or you're looking into the psychiatric

00:38:10.880 | and psychological textbooks,

00:38:12.020 | what you would find is that there's a huge constellation

00:38:14.220 | of eating disorders.

00:38:15.060 | Today, we're mainly going to talk about anorexia,

00:38:17.600 | bulimia, binge eating disorder, and body dysmorphia.

00:38:21.360 | You can even find eating disorders like pica,

00:38:23.940 | where people actually ingest things like dirt

00:38:27.220 | or rocks or metal because they have a genuine appetite

00:38:30.760 | for those things.

00:38:31.600 | I certainly do not recommend sampling any

00:38:34.600 | of those non-food items as foods.

00:38:36.800 | It is incredibly dangerous.

00:38:38.580 | People often poison themselves.

00:38:40.480 | They often can cause structural blockages.

00:38:43.920 | Some people have died from those sorts of things,

00:38:46.600 | but nonetheless, there are aspects of our brain and biology

00:38:50.520 | that when disrupted can lead

00:38:51.920 | to very bizarre types of eating behavior.

00:38:54.660 | Sometimes pica is caused by malnutrition, but not always.

00:38:58.160 | And so today we're going to focus

00:38:59.880 | on the most prevalent eating disorders,

00:39:01.980 | but we are going to build up toward that understanding

00:39:04.480 | by looking at what healthy metabolism

00:39:08.040 | and eating and satiety and hunger looks like.

00:39:10.960 | Because one, I realized that not everyone out there

00:39:13.340 | has an eating disorder.

00:39:14.680 | And two, I want people to understand this relationship

00:39:18.200 | between how they think, the decisions they take

00:39:21.920 | about what they eat and how the body and the brain

00:39:24.960 | at subconscious levels are driving some

00:39:27.640 | of these behaviors, healthy or otherwise,

00:39:30.320 | because I do think that it can lead us

00:39:32.180 | to a better understanding of what healthy eating is

00:39:34.780 | for most of us and to increase compassion

00:39:38.460 | and hopefully even increased improvement

00:39:41.100 | in treatment of eating disorders

00:39:43.040 | for those that are suffering from them.

00:39:45.100 | So what is hunger and what is satiety?

00:39:47.180 | Satiety, of course, being sated

00:39:49.100 | or feeling like we've had enough food.

00:39:51.340 | I want to remind people of the basic mechanisms

00:39:55.740 | by which the brain and body communicate.

00:39:57.640 | This is vitally important, not just for this discussion,

00:40:00.040 | but for any discussion about how we think,

00:40:03.440 | how we behave, how we feel.

00:40:05.600 | The body is communicating two types of information

00:40:08.280 | to the brain on a regular basis,

00:40:10.680 | but in particular around feeding.

00:40:13.040 | And those two types of information

00:40:14.360 | are mechanical information and chemical information.

00:40:18.800 | What do I mean by mechanical information?

00:40:20.360 | Well, if you take a deep breath and you hold your breath,

00:40:24.200 | what you'll find is that you can hold your breath

00:40:25.560 | a lot longer than if you exhale all your air

00:40:28.000 | and you hold your breath with lungs empty.

00:40:29.760 | And the reason is not because when your lungs are full,

00:40:32.860 | you have enough oxygen and therefore

00:40:34.840 | you can hold your breath.

00:40:35.760 | It's because when your lungs are full,

00:40:38.280 | a particular class of neurons called baroreceptors

00:40:41.200 | send information to the brain and say,

00:40:44.200 | there's pressure in the lungs.

00:40:45.360 | And that means that there's probably oxygen in here.

00:40:47.680 | And so the trigger to breathe is actually suppressed.

00:40:51.440 | When your lungs are empty,

00:40:52.720 | even if you have plenty of oxygen in your system,

00:40:55.180 | those baroreceptors send a different signal to the brain,

00:40:57.580 | which is there's no oxygen in here and you should breathe.

00:41:00.580 | And so the impulse to breathe comes earlier.

00:41:02.420 | Likewise, when your stomach is full,

00:41:05.320 | it sends signals to your brain

00:41:06.700 | that are purely based on this mechanical fullness,

00:41:09.660 | has nothing to do with nutrients that says I'm full

00:41:14.020 | and therefore don't be as hungry.

00:41:16.680 | Don't motivate to find or ingest food.

00:41:19.460 | Whereas when our gut is empty,

00:41:21.260 | even if we have plenty of nutrients

00:41:23.220 | or plenty of body fat stores,

00:41:25.260 | we tend to focus on food a bit more.

00:41:27.860 | So volume and mechanical influences have a profound effect

00:41:31.660 | on how we think and what we consider doing or not doing.

00:41:35.620 | Likewise, chemical effects.

00:41:37.820 | When we ingest food,

00:41:39.180 | our so-called blood sugar or blood glucose levels go up.

00:41:41.940 | That information is signaled to the brain

00:41:44.460 | via neuronal pathways and hormonal pathways.

00:41:48.940 | And in particular, there are neurons within our gut

00:41:51.420 | that signal to areas of our brainstem

00:41:53.240 | that are involved in satiety in our sense of having enough

00:41:56.140 | that there's food in our system.

00:41:58.380 | So that's chemical information.

00:42:00.480 | So how are hunger and feeding and satiety regulated?

00:42:05.480 | By way of mechanical and chemical signaling.

00:42:07.820 | You have, I have, we all have neurons in our hypothalamus

00:42:12.780 | that trigger eating and neurons that trigger cessation

00:42:17.560 | or stopping of eating.

00:42:18.740 | We have an accelerator on eating and we have a break.

00:42:21.180 | And I covered all of this in a lot of detail

00:42:23.780 | in the episode on feeding and metabolism and hunger.

00:42:26.680 | So if you want a lot more detail, see that episode.

00:42:29.760 | But right now, I'm just going to give you the top contour

00:42:32.060 | of how all that works.

00:42:34.060 | Your hypothalamus is an area of your forebrain,

00:42:36.100 | which tells you it's in the front,

00:42:37.920 | but it's at the base of your forebrain,

00:42:39.360 | sits more or less above the roof of your mouth.

00:42:41.380 | The hypothalamus contains lots of different kinds of neurons,

00:42:44.380 | including neurons that stimulate sexual activity and desire,

00:42:48.020 | regulate your body temperature

00:42:50.080 | and control appetite and ceasing of eating and appetite.

00:42:55.080 | There are two types of neurons

00:42:58.180 | within a particular area of your hypothalamus

00:42:59.920 | that are relevant here.

00:43:01.200 | There are the so-called POMC neurons, okay?

00:43:05.720 | Pro opioid melanocortin neurons

00:43:08.860 | that tend to act as more of a break on appetite

00:43:13.580 | by way of another hormone

00:43:15.040 | called melanocyte stimulating hormone.

00:43:16.780 | And not so incidentally,

00:43:18.720 | when you're getting a lot of sunlight

00:43:19.980 | and you're viewing a lot of sunlight,

00:43:21.260 | that system is ramped up.

00:43:23.160 | This is why appetite is lower in the summer months

00:43:25.920 | than it is in the winter months.

00:43:27.440 | This is true in animals and this is true in humans.

00:43:30.840 | And you have a class of neurons called the AGRP neurons.

00:43:34.020 | The AGRP neurons are the ones that stimulate feeding

00:43:37.680 | and they create a sort of anxiety or excitement about food.

00:43:41.640 | Can be positive anxiety or it can be negative anxiety.

00:43:45.480 | What do I mean by that?

00:43:46.460 | Well, have you ever seen kids heading in to get ice cream?

00:43:49.860 | They're absolutely excited.

00:43:51.200 | You see people getting ready to sit down

00:43:52.920 | and eat a big meal.

00:43:54.400 | They're excited to eat.

00:43:55.500 | Sometimes that's due to social factors,

00:43:57.280 | but they have an increase in overall levels

00:43:59.640 | of autonomic arousal.

00:44:01.160 | And depending on the context,

00:44:02.640 | they can feel excited or anxious,

00:44:04.280 | but it is a ramping up of energy.

00:44:06.260 | These AGRP neurons are what caused that.

00:44:09.480 | In fact, so much so that if you eliminate

00:44:12.420 | or kill these neurons,

00:44:13.400 | which has been done in experimental mouse models

00:44:16.140 | in the laboratory,

00:44:16.980 | but also there are humans that have lesions

00:44:18.760 | or neurotoxic effects on these AGRP neurons.

00:44:21.940 | And what you find is that they don't want to eat.

00:44:24.080 | They essentially become anorexic,

00:44:26.480 | meaning they don't want to ingest food.

00:44:28.280 | They have no appetite for food whatsoever.

00:44:31.220 | Now that's not exactly what anorexia is,

00:44:33.400 | but these AGRP neurons are like an accelerator

00:44:35.840 | on wanting to eat.

00:44:36.920 | Whereas if you stimulate these AGRP neurons

00:44:39.600 | or in humans that have say a small tumor

00:44:42.360 | near these AGRP neurons, they become hyperphagic.

00:44:44.920 | They will eat to the point of bursting,

00:44:47.060 | both animals and humans that have elevated levels

00:44:49.780 | of these AGRP neurons are anxious.

00:44:52.660 | They want to eat and they will ingest food

00:44:55.260 | to the point where they override those mechanical

00:44:57.420 | and chemical signals in the body.

00:44:58.760 | And I know it sounds horrible and it is horrible.

00:45:01.180 | They will eat until the point that they burst.

00:45:04.100 | Now there are signals coming back from the body

00:45:07.280 | to inform the brain about presence

00:45:09.160 | of different levels of nutrients.

00:45:11.100 | And that generally comes from three sources.

00:45:13.420 | First of all, is body fat.

00:45:16.720 | The more body fat we have,

00:45:18.040 | the more we secrete a hormone called leptin,

00:45:20.440 | L-E-P-T-I-N, leptin from body fat.

00:45:23.320 | Leptin goes to the brain and suppresses appetite.

00:45:27.140 | This is a body to brain signaling mechanism that says,

00:45:30.460 | look, I've had enough.

00:45:32.580 | Not incidentally, leptin signaling is disrupted

00:45:36.480 | in people that have bulimia and obesity

00:45:39.680 | and certain forms of binge eating disorder.

00:45:42.440 | So that system is disrupted.

00:45:44.680 | I've had enough signal or there's enough body fat here

00:45:47.440 | such that you don't need to eat more.

00:45:49.760 | Right here, I'm sort of in the voice of the body fat

00:45:51.880 | trying to talk to the brain.

00:45:52.920 | That signal, that dialogue is mixed up or messed up.

00:45:56.080 | In some cases, it's absent entirely.

00:45:58.340 | So the body fat is signaling to the brain

00:46:00.780 | about how much reserve you have.

00:46:02.780 | It's sort of like a savings account for energy

00:46:05.120 | 'cause that's what body fat is.

00:46:06.520 | You've got lipids in there and through lipolysis,

00:46:08.480 | they can be metabolized.

00:46:09.480 | If you're interested in that process,

00:46:12.000 | both how to increase it and just generally how it works,

00:46:15.240 | you can see the episode on the science of fat loss.

00:46:18.480 | The body fat is doing something else really interesting

00:46:20.480 | that relates to anorexia.

00:46:22.860 | When there's sufficient levels of body fat

00:46:24.800 | and leptin circulating in the blood

00:46:27.240 | and that leptin signal gets to the brain,

00:46:29.920 | the hypothalamus and the pituitary gland

00:46:32.480 | register that signal and in a completely subconscious way,

00:46:37.440 | trigger the deployment of eggs in females

00:46:41.880 | and the production of sperm in males.

00:46:44.900 | So when body fat stores are very low,

00:46:47.140 | the reason why periods shut off

00:46:49.200 | or sperm production is reduced or even shut off

00:46:52.200 | is because there's not enough leptin

00:46:53.980 | getting to the hypothalamus and to the pituitary

00:46:57.680 | and they shut off the signals, the hormones,

00:47:00.460 | things like gonadotropin-releasing hormone,

00:47:02.120 | luteinizing hormone, follicle-stimulating hormone,

00:47:04.360 | all these hormones that you don't have to remember

00:47:05.840 | the names of if you don't want to,

00:47:07.980 | that travel to the ovary or to the testes

00:47:10.280 | and cause the ovary and testes to ovulate

00:47:12.840 | or to produce more sperm.

00:47:15.560 | So the reason why anorexics stop having periods

00:47:18.320 | when they stop cycling

00:47:20.600 | is because there isn't sufficient leptin in the bloodstream.

00:47:24.000 | Now, there have been attempts to give leptin to anorexics

00:47:28.520 | because leptin has been sequenced

00:47:30.560 | and the peptide has been synthesized

00:47:32.640 | and so you can inject leptin into people.

00:47:35.320 | There are studies where they've done that.

00:47:37.480 | When that happens, it does not tend

00:47:40.420 | to alleviate the anorexia.

00:47:42.840 | It does not cause people to start eating again

00:47:44.800 | and that actually makes sense

00:47:46.080 | because leptin is also a way

00:47:47.880 | of shutting off the hunger signals saying,

00:47:50.300 | it's the body fat's way of saying,

00:47:51.640 | hey, there's a lot of body fat here

00:47:52.880 | or there's sufficient body fat.

00:47:54.120 | There doesn't even have to be a lot,

00:47:56.120 | but it has in some cases been shown to rescue

00:47:59.340 | the menstrual cycling in some anorexics.

00:48:02.260 | Okay, so body fat is signaling to the brain.

00:48:04.760 | The gut is signaling to the brain.

00:48:06.300 | There are neurons in your gut

00:48:07.760 | that are primarily responding to,

00:48:10.780 | meaning they fire electrical signals

00:48:12.360 | when there are sufficient fatty acids

00:48:14.440 | coming from fats you ingest,

00:48:16.640 | amino acids coming from proteins you ingest

00:48:18.960 | and sugars coming from carbohydrates and sugars,

00:48:21.920 | things like fructose, glucose, et cetera.

00:48:23.920 | Those signals are being sent from the fat

00:48:27.400 | and from the gut up to the brain

00:48:29.160 | and therefore your body has multiple signals

00:48:34.340 | of directing you toward eating more or eating less.

00:48:38.480 | So you've got two categories of neurons,

00:48:40.080 | one that acts as an accelerator,

00:48:41.840 | the AGRP neuron saying, eat, eat,

00:48:44.340 | and gets you excited to eat.

00:48:45.820 | And then you have a category of neurons,

00:48:48.500 | the PMOC neurons that are suppressing hunger.

00:48:51.840 | They're acting like a break

00:48:52.960 | and the body is informing the brain all the time

00:48:55.800 | about the status of the body

00:48:57.200 | and whether or not it needs more food or not.

00:48:59.780 | So you might ask, why is it that people who are overweight

00:49:02.400 | and have a lot of body fat,

00:49:03.960 | why they would continue to eat a lot?

00:49:05.700 | Well, past a certain threshold of body fat,

00:49:08.040 | that's when you start getting

00:49:08.860 | into these so-called metabolic disorders

00:49:10.880 | where blood glucose metabolism is disrupted,

00:49:13.360 | leptin signaling is disrupted,

00:49:15.200 | and there are all sorts of changes

00:49:16.580 | on both the brain side and the body end of things

00:49:20.640 | such that they're hungry despite the fact

00:49:23.160 | that the body has plenty of energy on reserve.

00:49:26.200 | Okay, that I think is sufficient to explain

00:49:30.080 | the basics of hunger and satiety

00:49:32.360 | and a kind of a biological mechanism.

00:49:33.940 | And the important thing again to remember

00:49:35.380 | is that they're mechanical and chemical signals

00:49:37.660 | that come from fullness or absence of fullness.

00:49:40.000 | They come from the presence of glucose in the blood

00:49:41.880 | or the absence of glucose in the blood.

00:49:43.920 | When you haven't eaten for a long time,

00:49:45.360 | glucagon levels go up, for instance, GLP-1 levels go up,

00:49:49.620 | and those will drive you to seek out food and want food.

00:49:52.160 | And then there are these signals

00:49:53.400 | that are coming from body fat and from neurons in the gut.

00:49:56.000 | So there's a lot of convergence signal, lot of pathways.

00:49:58.760 | I don't offer you all those pathways to confuse you.

00:50:01.080 | I offer you those pathways to clarify the extent

00:50:05.360 | to which something as simple as eating

00:50:08.200 | or the decision to not eat is complicated.

00:50:11.540 | We've perhaps heard, or I've certainly heard that,

00:50:14.400 | oh, you know, it takes about 20 minutes

00:50:16.560 | for satiety to set in, you know, so you should eat slowly,

00:50:19.500 | that you won't realize that you're full

00:50:20.840 | until about 20 minutes.

00:50:22.480 | That's actually not true.

00:50:23.800 | I don't know where that got started,

00:50:24.920 | but we should probably all chew our food better

00:50:26.860 | and eat more slowly,

00:50:28.240 | be more mindful of what we're eating, et cetera.

00:50:30.780 | So in anticipation of this episode,

00:50:34.200 | I consulted extensively with a colleague of mine at Stanford

00:50:37.080 | who sadly for us is going off to University of Pennsylvania.

00:50:40.600 | So our loss is University of Pennsylvania's win.

00:50:44.160 | His name is Dr. Casey Halpern.

00:50:46.120 | He's a MD, medical doctor and neurosurgeon,

00:50:49.800 | and a PhD who studies binge eating disorder

00:50:52.260 | and other types of eating disorders

00:50:54.100 | and how they arise in the brain.

00:50:55.800 | And he's developed some really pioneering treatments

00:50:58.600 | for them.

00:51:00.080 | We'll talk more about his work

00:51:01.260 | a little bit later in the episode,

00:51:03.080 | but we got to the discussion of why a body

00:51:08.000 | that has sufficient energy levels

00:51:10.020 | would desire to eat more at all.

00:51:12.820 | And this is not just the case for binge eating disorder

00:51:15.360 | or for bulimia, but why that would be the case.

00:51:17.740 | You know, this is primitive biology

00:51:19.520 | that evolved over many tens,

00:51:21.180 | if not hundreds of thousands of years,

00:51:22.540 | you see it in mice, you see it in humans,

00:51:24.300 | very similar types of pathways and effects.

00:51:27.340 | How is it that human beings who have plenty of fat

00:51:31.180 | on reserve and plenty of glycogen in their liver, et cetera,

00:51:34.700 | in other words, plenty of energy,

00:51:36.240 | why they would be hungry, why they would eat at all.

00:51:39.240 | It seems like that just shouldn't happen.

00:51:41.940 | And he had a very important and I think clear

00:51:46.420 | and intuitive way of framing up all this stuff

00:51:49.700 | around eating and motivated behaviors

00:51:51.460 | and how they can go awry,

00:51:53.220 | not just in eating disorders, but in all of us.

00:51:56.880 | Basically what he said was from an evolutionary standpoint,

00:52:01.880 | it makes sense that we should eat as often as we can,

00:52:06.640 | as much as we can, and as fast as we can.

00:52:10.280 | Well, that sounds crazy.

00:52:11.520 | I was told to eat not too often, not too much,

00:52:16.340 | and to eat slowly and chew my food.

00:52:18.780 | But as Dr. Halperin pointed out,

00:52:21.960 | there are circuits in the brain to reward eating often,

00:52:24.600 | eating fast and cramming as much food into you as possible,

00:52:29.380 | because from a purely evolutionary standpoint,

00:52:32.180 | food was scarce and seeking food was dangerous,

00:52:36.460 | whether or not it was from animal sources or not.

00:52:38.940 | And it's always been competitive.

00:52:41.840 | For those of you that grew up in families

00:52:43.180 | with a lot of siblings, this may resonate with you.

00:52:45.460 | I had just one sibling.

00:52:47.340 | We were competitive about certain things,

00:52:48.680 | but typically not competitive about food.

00:52:50.420 | But I had friends that had a lot of siblings.

00:52:52.740 | It was really interesting to see how food was served up

00:52:55.580 | and how it was taken in those households.

00:52:59.960 | It was like food would hit the table

00:53:01.200 | and it was just an absolute war for portions.

00:53:05.520 | And who got what and how much

00:53:07.480 | and who got a slightly bigger piece of cake, et cetera,

00:53:10.080 | turned out to be a frequent happening in these meals

00:53:14.000 | and at these birthday parties.

00:53:15.580 | Whereas the only children perhaps

00:53:17.740 | were used to having more food presented to them

00:53:20.300 | without having to compete with other members of the species.

00:53:23.000 | Every animal, including humans,

00:53:25.340 | has a hardwired circuit that we were born with

00:53:28.700 | that pays attention to how much food is available,

00:53:32.140 | how much we are getting now

00:53:33.480 | and how much we are likely to get in the future.

00:53:36.280 | And without going down the rabbit hole

00:53:38.460 | of arcuate nucleus biology, in two sentences,

00:53:43.460 | you have a hypothalamic area called the arcuate nucleus.

00:53:46.980 | It's a fascinating area.

00:53:48.260 | It's actually the area that houses these PMOC neurons

00:53:51.380 | and these other types of neurons

00:53:52.440 | that regulate hunger and satiety.

00:53:55.220 | And these neurons in the arcuate nucleus

00:53:58.240 | start getting active when we see food and think about food.

00:54:02.240 | They drive hunger and they drive hunger

00:54:05.920 | in a way that's responsive to what the food looks like,

00:54:08.940 | what it smells like,

00:54:10.460 | but also our prior history of interactions with that food.

00:54:14.100 | And it takes into account social context,

00:54:17.300 | whether or not we are going to get the whole pizza

00:54:20.060 | to ourselves or whether or not there are going to be others

00:54:23.220 | that we are going to have to compete with.

00:54:24.720 | So there are a lot of signals that this arcuate nucleus

00:54:27.380 | in your brain are paying attention to.

00:54:29.580 | So Dr. Halpern pointed out

00:54:31.440 | that you actually have an accelerator

00:54:33.940 | that increases your level of awareness and anxiety

00:54:36.940 | and sort of constricts your field of view

00:54:39.340 | and all your senses anytime you interact with food

00:54:42.140 | and is driving a primitive reflex

00:54:44.180 | to ingest as much food as you can as quickly as you can,

00:54:48.100 | and then move on from there

00:54:49.660 | and presumably to do the same elsewhere.

00:54:52.120 | So that changed the way that I think about eating behavior

00:54:56.380 | and eating disorders.

00:54:58.180 | In fact, we could think about eating disorders like bulimia

00:55:01.520 | as an unmasking of that mechanism

00:55:03.760 | without the so-called top-down control,

00:55:05.540 | without the mechanisms that we use to regulate our behavior.

00:55:09.180 | And indeed, bulimia and binge eating disorder

00:55:12.420 | are closely associated with impulsivity

00:55:15.740 | and with impulsive behaviors of other kinds,

00:55:18.780 | something that we also will discuss more.

00:55:21.780 | What's the pathway?

00:55:22.680 | How does this work?

00:55:23.520 | What is Dr. Halpern and his colleagues doing

00:55:26.260 | in order to try and treat things like binge eating disorder?

00:55:28.900 | Well, you can frame all of behavior,

00:55:33.900 | good decision-making and bad decision-making,

00:55:36.920 | in a pretty simple box diagram model.

00:55:39.780 | And I realized that many of you are listening to this,

00:55:41.720 | not watching this.

00:55:42.720 | There is no diagram to look at.

00:55:44.100 | I'll just explain it

00:55:45.040 | so that you can conceptualize it in your mind.

00:55:47.380 | We have knowledge of what we should do in one box, okay?

00:55:52.560 | We should eat that.

00:55:53.480 | We shouldn't eat that.

00:55:54.440 | We should wait for dinner.

00:55:55.360 | We shouldn't wait for dinner.

00:55:57.500 | And then we have what we actually do in another box, okay?

00:56:02.020 | Now, this is true for all behaviors.

00:56:03.540 | We should say something or we want to say something,

00:56:06.080 | but we don't.

00:56:06.960 | We shouldn't say something, but we do anyway.

00:56:09.000 | That's the knowledge, the kind of looping in your head.

00:56:11.960 | I should do my homework.

00:56:13.080 | I should go for a run.

00:56:14.400 | I shouldn't do this right now.

00:56:15.840 | I shouldn't be on social media.

00:56:17.500 | All those kinds of shoulds and shouldn'ts

00:56:19.280 | that are circulating in your head, that's one box.

00:56:21.460 | Then there's what you actually do, the behavior,

00:56:23.720 | whether or not you suppress the behavior,

00:56:25.520 | you turn off your phone and you go read a book

00:56:27.800 | or you go to sleep or whether or not you stay up all night

00:56:30.480 | or you stay up for another hour, even five minutes.

00:56:33.500 | In between those two boxes are two intervening forces.

00:56:37.080 | And those intervening forces are critically important.

00:56:39.940 | Those intervening forces are homeostatic processes

00:56:43.300 | called by some processes, same thing.

00:56:46.760 | Homeostatic processes that regulate the balance

00:56:51.700 | of different systems in your body, hot and cold,

00:56:54.200 | awake or asleep, dopamine and the desire to pursue things,

00:56:58.760 | serotonin and the desire to just relax and chill.

00:57:02.260 | So homeostatic processes and reward systems.

00:57:06.780 | And as we now move into discussion

00:57:08.800 | about anorexia and bulimia specifically,

00:57:11.620 | what you'll see is that anorexia and bulimia

00:57:15.900 | are not a breaking of the mindset

00:57:18.840 | of what one should do or shouldn't do.

00:57:21.920 | It's a disruption of these homeostatic and reward processes

00:57:26.280 | such that decision-making is completely disrupted

00:57:29.160 | and in many cases is not available

00:57:31.200 | to the anorexic or bulimic.

00:57:33.080 | Now, I don't want to be abstract here.

00:57:34.480 | What I'm saying is that the person who starves themselves

00:57:38.780 | to the point where they might die

00:57:40.320 | and in some cases sadly do die,

00:57:42.860 | they can know perfectly well that their behavior

00:57:46.060 | is leading to bad outcomes and possibly even death.

00:57:50.500 | And yet they are not able to intervene

00:57:53.580 | unless they get particular clinical help

00:57:55.900 | because the homeostatic processes,

00:57:59.800 | the signals from the body and brain that say you need food,

00:58:03.500 | those aren't registering in the same way

00:58:05.880 | that they are for other individuals.

00:58:08.120 | And for the bulimic or the person that suffers

00:58:10.400 | from binge eating disorder,

00:58:12.080 | they don't necessarily want to eat that food.

00:58:14.880 | They simply cannot help it.

00:58:17.320 | It's like a reflex for them

00:58:18.880 | because the homeostatic processes

00:58:22.060 | and the reward processes associated with food

00:58:24.700 | are such that they can't intervene

00:58:26.840 | between the should do X, Y, or Z,

00:58:30.020 | or shouldn't do X, Y, or Z and what their actual behavior is.

00:58:33.060 | Now, this isn't just a biological mechanistic explanation

00:58:37.160 | for what could have been summarized in two sentences.

00:58:39.620 | What this is is a roadmap

00:58:42.280 | of where interventions can really make a difference.

00:58:45.360 | So as we talk about different drug-based interventions

00:58:48.360 | or behavioral interventions or social interventions,

00:58:51.760 | I'd like you to think about whether or not

00:58:54.720 | those interventions are breaking into

00:58:58.320 | or tapping into this box of the thinking,

00:59:01.040 | the sort of pattern of thinking around food,

00:59:03.620 | whether or not it's the behavior,

00:59:04.660 | the actual ingestion or the restriction of food,

00:59:07.280 | or whether or not it's tapping into the homeostatic process,

00:59:09.940 | the balance of energy systems

00:59:11.560 | and kind of getting enough but not too much,

00:59:14.100 | or it's tapping into the reward system.

00:59:16.920 | And just as a little teaser of where we're headed,

00:59:20.040 | what you'll find based on the data,

00:59:22.360 | clinical data experiments done very carefully

00:59:24.840 | and very well by excellent groups,

00:59:27.020 | what you'll find is that anorexics

00:59:29.460 | have a sort of switch that's been flipped

00:59:32.740 | such that their decision-making

00:59:34.400 | is actually pretty darn good.

00:59:36.120 | It might even be better than yours

00:59:37.760 | in terms of evaluating food nutritional content,

00:59:40.980 | but their habits are disrupted.

00:59:43.200 | So they're not even consciously aware of the fact

00:59:45.660 | that they're making terrible

00:59:46.980 | and in some cases very dangerous food choices.

00:59:49.540 | It turns out that habits

00:59:52.800 | and the way that we build and break and rebuild new habits

00:59:56.760 | is one of the most effective treatments for anorexia.

00:59:59.520 | So now let's talk about anorexia,

01:00:01.060 | this failure to consume enough energy

01:00:03.200 | such that the individual is at risk of death.

01:00:06.200 | And if not death, then severe metabolic disorders,

01:00:09.080 | lack of bone density, et cetera.

01:00:12.420 | As I mentioned earlier,

01:00:13.600 | anorexia and things that almost certainly were

01:00:17.780 | and are anorexia have been described

01:00:19.260 | as early as the 1600s and maybe even earlier.

01:00:22.220 | There are some records from the saints,

01:00:24.280 | from the 1400s of people that refuse to ingest food.

01:00:28.180 | Another common myth is that anorexia

01:00:32.120 | is only the sort of thing that you see in rich societies.

01:00:37.120 | These are spoiled children with so much food

01:00:39.980 | that they decide they're only going to focus on

01:00:42.620 | how slim they are, how they look in bathing suits, et cetera.

01:00:46.080 | Not true.

01:00:47.320 | A careful analysis through medical epidemiology

01:00:50.560 | has shown that you find anorexia

01:00:52.620 | even in cultures and societies where food is scarce.

01:00:56.240 | So that really speaks to biological mechanism.

01:00:58.700 | Now it's hard to unveil in societies where food is scarce

01:01:02.200 | because a lot of people are starving and hungry,

01:01:05.340 | but there are individuals that choose still to avoid food

01:01:09.720 | and seem to have some sort of reward mechanism

01:01:12.440 | that rewards them or makes them feel better

01:01:15.580 | if they don't eat despite the fact

01:01:17.960 | that their body is severely depleted of nutrients.

01:01:22.000 | So that's very interesting and points again

01:01:23.820 | to some disruption in some biological mechanism.

01:01:26.540 | Now, I want to make sure that I'm emphasizing

01:01:29.620 | that I'm not in favor of people,

01:01:32.520 | in particular young children,

01:01:34.460 | adolescents and teenagers being bombarded

01:01:36.320 | with unrealistic imagery about bodies.

01:01:39.040 | But the idea that that's the cause of,

01:01:41.720 | or is amplifying anorexia,

01:01:44.080 | the data just don't seem to support that.

01:01:46.800 | Anorexia in its classic sense

01:01:49.740 | requires that there be an endocrine,

01:01:52.600 | meaning a hormonal disruption,

01:01:54.880 | menstrual abnormalities,

01:01:56.360 | lack of sperm production or low testosterone in males

01:01:59.900 | in order to meet the classification for anorexia.

01:02:03.520 | But as I mentioned earlier,

01:02:04.560 | there are now nuanced and new classifications of anorexia

01:02:09.280 | that even for individuals that still menstruate

01:02:11.740 | or that maintain sperm production,

01:02:14.300 | that anorexia can still be considered

01:02:16.660 | a clinically diagnosable disorder.

01:02:19.240 | Now, typically anorexia starts in adolescents

01:02:22.580 | right around puberty.

01:02:23.600 | Let's take a look at what puberty is.

01:02:25.400 | Puberty at a very broad level

01:02:28.320 | is the most significant and dramatic developmental step

01:02:31.940 | anyone goes through in their lifespan.

01:02:33.840 | The body changes, the brain changes,

01:02:35.320 | perceptions change, one's own self perception changes.

01:02:39.360 | And most of those changes are driven by changes

01:02:42.500 | in circuitry within the hypothalamus.

01:02:45.080 | So neurons that are controlling the production

01:02:46.980 | of the so-called sex steroid hormones,

01:02:49.520 | things like testosterone, estrogen and related hormones,

01:02:52.060 | prolactin, et cetera,

01:02:53.400 | those are all changing at very rapid rates.

01:02:56.360 | Anorexia tends to show up around this time

01:03:00.060 | in a subset of individuals who on the face of it

01:03:03.840 | seem to find food aversive.

01:03:06.080 | Now, the purely psychological theory of this

01:03:08.240 | is that they are fighting for autonomy.

01:03:10.520 | They want control.

01:03:11.800 | Puberty is also a time in which children and parents

01:03:14.520 | are in a tug of war over control.

01:03:17.200 | You were once a small child

01:03:19.100 | being told when to go to bed, sent to your room.

01:03:21.400 | Now you're a child that can talk back and say,

01:03:23.820 | I don't want to, or I refuse to.

01:03:26.180 | And that happens a lot in various households

01:03:29.160 | as I'm sure you're familiar with.

01:03:30.860 | Adolescence and puberty is also

01:03:34.180 | when girls start menstruating typically

01:03:37.460 | or boys develop deeper voice,

01:03:41.860 | they start producing sperm, et cetera.

01:03:44.420 | So there are a lot of bodily changes

01:03:45.760 | that also drive perceptual changes

01:03:47.480 | and perceptual changes that drive bodily changes.

01:03:49.520 | And it is a dramatic shift for a young girl or boy

01:03:54.520 | that doesn't nourish themselves sufficiently

01:03:56.720 | during that period.

01:03:57.560 | There are a number of downstream negative effects.

01:04:00.360 | I'll list out some of them.

01:04:01.580 | These are just a subset of the effects.

01:04:04.280 | Hypogonadism, that's the lack of sperm production

01:04:07.820 | or healthy egg production.

01:04:10.060 | There is amenorrhea, which is the lack of menstrual cycling.

01:04:15.060 | So a failure to have a menstrual cycle.

01:04:17.660 | Reduced insulin secretion.

01:04:18.980 | Insulin is this hormone that's released

01:04:20.900 | in order to help shuttle glucose

01:04:23.320 | into various tissues for energy utilization.

01:04:25.620 | That's down because energy levels are down so much.

01:04:28.300 | One of the symptoms that's a little more cryptic

01:04:30.180 | and that has actually interesting implications

01:04:32.460 | for sake of the cholesterol hypothesis

01:04:34.860 | is that anorexics who ingest very little food

01:04:40.020 | often have cosmically high levels of cholesterol,

01:04:42.860 | including LDL, low density lipoprotein cholesterol.

01:04:45.980 | You say, well, how could that possibly be it?

01:04:47.460 | We were all told and continue to be told from many sources

01:04:50.780 | that ingestion of dietary cholesterol

01:04:53.460 | is what drives high levels of bodily cholesterol.

01:04:55.900 | Cholesterol is manufactured by the liver.

01:04:58.120 | And in anorexics who consume very little food,

01:05:02.920 | they often have cosmically high levels of cholesterol,

01:05:06.100 | which is one of the kind of wrinkles

01:05:08.520 | in the so-called dietary cholesterol hypothesis

01:05:11.540 | that all of our cholesterol that we see on a blood panel

01:05:14.580 | is due to what we eat.

01:05:16.360 | But the explanation for it is that under conditions

01:05:19.580 | where there's not sufficient cholesterol

01:05:21.220 | to synthesize the sex steroid hormones,

01:05:23.360 | things like testosterone and estrogen,

01:05:24.960 | which are required in both males and females,

01:05:27.100 | those are made from cholesterol,

01:05:29.860 | that the body, the liver will start generating

01:05:32.820 | its own cholesterol and will often overshoot the mark

01:05:36.120 | to a dramatic degree.

01:05:37.520 | So the blood lipid profiles in anorexics

01:05:39.820 | are often very unhealthy,

01:05:41.540 | despite the fact that they're eating very little food.

01:05:44.820 | In addition, they tend to have elevated levels

01:05:46.980 | of things like vasopressin,

01:05:48.560 | which are hormones that regulate body temperature

01:05:50.860 | and salt and blood volume.

01:05:54.140 | They tend to have low blood pressure.

01:05:55.380 | They can pass out.

01:05:56.340 | I mentioned some of the other symptoms earlier.

01:05:58.640 | In other words, there are a huge number

01:06:01.740 | of terrible things happening.

01:06:03.060 | Thyroid levels are down, heart rates are down.

01:06:06.180 | If I'm painting a very bleak picture here,

01:06:07.980 | it is indeed a bleak picture.

01:06:10.220 | So we have to ask ourselves what can be done

01:06:13.260 | for the anorexic, right?

01:06:16.040 | Let's say it's a failure of the AGRP neurons

01:06:19.260 | to stimulate appetite and feeding.

01:06:21.940 | Let's say it's too much anxiety around food.

01:06:24.180 | Let's say it's because of the way that food restriction

01:06:27.180 | was used for reward in the household, right?

01:06:29.320 | I'm making this up,

01:06:30.160 | but you can imagine a hypothetical scenario

01:06:31.820 | where let's just say the mother

01:06:35.200 | of a particular individual is very vocal

01:06:37.660 | about her avoidance of food.

01:06:39.080 | We've seen this before, right?

01:06:40.260 | You've probably seen somebody who loves to cook

01:06:42.280 | and prepare food, but then sits down

01:06:43.700 | and doesn't seem to eat.

01:06:44.540 | And they always seem to in air quotes have eaten earlier.

01:06:47.320 | I ate while I cooked, I ate while I cooked, right?

01:06:49.900 | These people that you never actually see eating.

01:06:52.800 | We all know people like this.

01:06:53.740 | Are they anorexic?

01:06:54.640 | Possibly, we don't know.

01:06:57.000 | A child observes that kind of behavior.

01:06:58.940 | Maybe that individual is being always being told

01:07:01.180 | how beautiful they look or how wonderful or fit they look,

01:07:04.160 | what incredible meals they produce.

01:07:06.560 | And you could imagine a purely psychosocial set of events

01:07:11.560 | that could lead a child to be anorexic.

01:07:14.920 | That doesn't seem to be the case,

01:07:16.900 | at least not in terms of driving classic anorexia

01:07:20.360 | of really extreme deprivation of oneself from food.

01:07:25.180 | However, there's a strong genetic component for anorexia.

01:07:28.760 | So you could imagine a mild form of anorexia in a parent

01:07:32.760 | that is supported or exacerbated by praise

01:07:37.680 | so that the person feels good

01:07:39.140 | from the praise they're getting,

01:07:40.760 | that they want to be a low body weight for whatever reason,

01:07:44.440 | for aesthetic reasons or for whatever reasons

01:07:46.800 | that happen to appeal to them.

01:07:48.440 | And the child has a genetic predisposition, right?

01:07:52.400 | We never think about genes in terms of controlling behavior,

01:07:55.300 | genes bias probabilities for behavior, okay?

01:07:59.320 | So you can have a gene for depression or for schizophrenia,

01:08:01.740 | but it's not deterministic in the same way

01:08:04.240 | that there are genes that determine your eye color

01:08:06.800 | or your skin color or your hair color, okay?

01:08:10.280 | So there's a genetic predisposition there.

01:08:13.020 | And that genetic predisposition could exist

01:08:15.220 | such that if one is rewarded enough times

01:08:18.680 | for a particular behavior,

01:08:20.340 | that behavior can start to ratchet in

01:08:24.020 | to our neural circuitry

01:08:25.220 | because behavior drives neural changes,

01:08:27.080 | so-called neuroplasticity.

01:08:28.360 | And you could imagine that that child

01:08:30.840 | could develop a full-blown case of anorexia.

01:08:33.200 | And this is why I raised at the beginning

01:08:35.060 | that no one really knows how to define healthy eating.

01:08:38.240 | And so therefore we have to rely

01:08:40.860 | on just identification of unhealthy behaviors.

01:08:43.880 | But what do we point people to

01:08:45.100 | in terms of what healthy replacement behaviors would be?

01:08:48.700 | So rather than just look at anorexics and say,

01:08:51.360 | they're not eating enough,

01:08:52.400 | and there's this huge array of terrible things

01:08:54.680 | that they're doing to their body and they need to eat more,

01:08:57.240 | we need to rescue them from themselves.

01:08:59.680 | Let's look under the hood.

01:09:00.920 | Let's look at what's known about the neural circuitry

01:09:03.440 | and the sorts of perceptions and behaviors

01:09:05.760 | of the neural circuitry is driving

01:09:07.760 | in order to understand what they are truly suffering from

01:09:11.760 | at the level of cause, not just symptoms.

01:09:14.160 | It's clear what they're suffering from

01:09:15.440 | at the level of symptoms.

01:09:17.040 | Symptoms are how we diagnose.

01:09:19.240 | I listed off a number of those things.

01:09:21.720 | But let's look under the hood and try and identify

01:09:24.640 | where one could intervene in theory

01:09:28.620 | in order to try and rescue the anorexic

01:09:31.280 | or help the anorexic rescue themselves.

01:09:34.400 | Because it turns out that the answer,

01:09:37.560 | or at least one of the answers of how to do that

01:09:39.620 | is not intuitive at all.

01:09:41.200 | At least to me was very surprising.

01:09:43.480 | I would be remiss if I didn't start with the obvious,

01:09:46.080 | which is, is there a chemical defect?

01:09:50.000 | Meaning, is there some disruption

01:09:52.200 | in one of the major chemical systems in the brain

01:09:54.880 | that makes anorexics anorexic?

01:09:57.240 | And therefore, can we replace that chemical

01:09:59.820 | or can we reduce some chemical

01:10:01.300 | and essentially eliminate anorexia?

01:10:04.100 | And the answer is not really sort of, maybe no.

01:10:07.640 | Here's why.

01:10:10.100 | There are a lot of different chemicals in the brain and body,

01:10:13.240 | but there are a category of chemicals

01:10:16.060 | that are particularly important

01:10:17.520 | that if you've listened to this podcast before,

01:10:19.300 | even if you haven't,

01:10:20.800 | are going to come up again and again and again.

01:10:23.400 | And that is the category of chemicals in the brain and body

01:10:25.840 | called the neuromodulators.

01:10:27.720 | Neuromodulators are different than neurotransmitters

01:10:30.520 | in the sense that neuromodulators modulate

01:10:32.480 | or change the activity of brain areas and neural circuits.

01:10:35.480 | You can think of them as microphones

01:10:37.760 | that are held between particular sets of connections

01:10:40.800 | in the brain that make those connections in the brain

01:10:42.960 | more likely to be active relative to others, okay?

01:10:46.800 | They make them louder, so to speak.

01:10:48.880 | There are many neuromodulators,

01:10:51.160 | but the ones that are important

01:10:52.280 | for sake of today's discussion are the classic ones.

01:10:55.340 | Dopamine, acetylcholine, norepinephrine, and serotonin.

01:10:58.980 | Let's focus on serotonin.

01:11:00.280 | Serotonin is a neuromodulator

01:11:03.120 | that tends to increase the activity

01:11:06.820 | of certain neural circuits,

01:11:08.540 | including within the hypothalamus, but also within the body,

01:11:11.560 | that trigger a sense of satiety of having enough,

01:11:16.240 | enough food, enough warmth, enough social connection,

01:11:21.040 | enough of any motivated goal or drive or any type of thing

01:11:26.040 | or behavior that one would want more of,

01:11:29.460 | serotonin tends to make those circuits quiet down.

01:11:33.660 | Now, there are many categories of drugs

01:11:37.380 | that emphasize the serotonergic circuitry,

01:11:40.560 | meaning they cause the release of

01:11:42.660 | or the efficiency of serotonin in the brain and body,

01:11:45.320 | things like Prozac, Zoloft, Paxil, things of that variety.

01:11:50.360 | Those drugs have been used to some degree of success,

01:11:54.200 | although not much, to treat things like anorexia nervosa.

01:11:58.440 | That should make sense

01:11:59.960 | because if these drugs increase serotonin,

01:12:02.820 | if their general effect is to increase serotonin,

01:12:05.380 | it will be to lower anxiety.

01:12:08.740 | That sounds like a great thing.

01:12:10.200 | A lot of anorexics are really anxious around food.

01:12:13.280 | We'll talk about why.

01:12:15.060 | Lowering anxiety, you might think,

01:12:16.560 | would lead to ingestion of more food,

01:12:18.640 | but that's not often what happens.

01:12:21.000 | Increasing serotonin by way of some drug regimen

01:12:25.320 | will tend to make one less hungry

01:12:27.640 | because with heightened levels of serotonin

01:12:31.320 | in the blood and brain,

01:12:33.360 | there isn't the desire to go seek out the things

01:12:35.780 | that will raise serotonin on their own.

01:12:37.760 | Now, some anorexics do well

01:12:40.040 | or benefit from these serotonergic drugs,

01:12:43.440 | these drugs that increase the activity of these circuits

01:12:45.760 | that lead to satiety.

01:12:47.140 | But if you think about the major goal

01:12:49.280 | of treating an anorexic,

01:12:51.820 | it's to get them to have more hunger, more appetite.

01:12:55.600 | So now I want to focus on some of the work

01:12:57.320 | that's been done around the habits

01:12:59.380 | and behaviors of anorexics,

01:13:01.240 | because those turned out to be ideal places

01:13:04.360 | for intervention.

01:13:05.320 | The work I'm about to describe

01:13:09.000 | was done by Dr. Joanna Steinglass and colleagues

01:13:11.860 | at Columbia University in New York.

01:13:13.780 | And there are other groups as well.

01:13:15.200 | Of course, they're doing this type of work,

01:13:16.880 | but they did what I think are really

01:13:19.220 | some beautiful experiments

01:13:20.780 | and some beautiful explorations

01:13:23.160 | of potential treatments for anorexics

01:13:25.000 | that seem to have a quite high degree of effectiveness

01:13:29.840 | when they are applied correctly.

01:13:32.280 | First of all, there's a challenge in studying anorexia

01:13:35.220 | because in anorexia, what you're essentially studying

01:13:38.360 | is the absence of a behavior.

01:13:40.360 | It's very hard to study the absence of a behavior

01:13:43.280 | as opposed to a behavior.

01:13:45.460 | So they did some experiments with anorexics,

01:13:47.580 | giving them a gallery of pictures of different foods

01:13:51.480 | and allowing those anorexic patients

01:13:54.080 | to arrange those foods according to preference

01:13:57.320 | about what they would select,

01:13:59.000 | about food nutrient content, about caloric content.

01:14:03.080 | They essentially asked these anorexics to evaluate food.

01:14:07.100 | And in doing so, they were able to identify

01:14:09.520 | something that's very unique to anorexics

01:14:12.140 | at the level of their perception of food.

01:14:15.260 | What they found is that anorexics,

01:14:17.800 | rather than being anxious in the presence of food

01:14:20.360 | and that anxiety driving an avoidance of food,

01:14:23.520 | what they found is that anorexics have a hyper acuity,

01:14:27.020 | a hyper awareness of the fat content of foods,

01:14:30.280 | almost to the point of being sort of fat content savants.

01:14:33.840 | Now, they don't necessarily know that they're doing this.

01:14:36.800 | They're not looking at an avocado and thinking,

01:14:38.480 | "Okay, that's X number of grams of fat," rather,

01:14:41.600 | or looking at an apple and saying, "Okay, that has no fat."

01:14:44.440 | They start to do this more or less reflexively.

01:14:47.080 | Now, it's a well-known symptom of anorexia,

01:14:49.860 | especially young anorexics,

01:14:51.820 | that they have kind of an obsession with food,

01:14:54.960 | caloric contents, macronutrient ratios,

01:14:57.320 | meaning fat, protein, and carbohydrate ratios.

01:15:00.900 | They know caloric numbers,

01:15:02.620 | but then they sort of pass that information

01:15:04.760 | into a memory system in their brain

01:15:07.280 | that allows their interactions with food

01:15:09.140 | to be very reflexive in a way

01:15:11.920 | that they are actively avoiding high fat content foods,

01:15:16.400 | calorie rich foods,

01:15:17.720 | and defaulting towards very low calorie foods

01:15:20.800 | if they have to eat.

01:15:22.980 | Now, this might seem like an almost trivial result

01:15:25.640 | on the face of it.

01:15:26.480 | You think, "Okay, they don't like to eat.

01:15:27.580 | When they do eat, they eat low calorie, low fat foods, duh."

01:15:30.800 | But it's the way in which they are doing this subconsciously

01:15:34.960 | that they learn this information

01:15:36.380 | and then they pass it off to a reflexive habit.

01:15:39.200 | And that's very important

01:15:40.680 | because what that means is that we need to look at

01:15:43.280 | what processes in the brain, what brain areas,

01:15:45.740 | what chemicals drive decision-making and knowledge.

01:15:49.920 | And we also need to look at the areas of the brain

01:15:52.280 | that drive habit formation and habit execution.

01:15:57.280 | Because for any of you that have habits,

01:15:59.640 | and that means all of you,

01:16:01.400 | the hallmark feature of a habit is that it's reflexive.

01:16:04.400 | You have a mosquito bite on your leg, you scratch it.

01:16:06.420 | You didn't necessarily even think,

01:16:07.760 | "Oh, I'm going to scratch that."

01:16:09.560 | In fact, just to take a little bit of a moment of respite

01:16:13.080 | and talk about habits in general,

01:16:15.760 | there's a beautiful study that was done

01:16:17.320 | out of Caltech University,

01:16:19.960 | looking at the parking lot of where people park

01:16:23.040 | in the morning without designated parking spots

01:16:25.780 | and the trajectories that they use

01:16:27.400 | to walk to their offices in the morning.

01:16:29.080 | So they put cameras up on the roof of Caltech.

01:16:30.860 | This is the kind of thing that the nerdy kids at Caltech do.

01:16:33.260 | I think at Caltech, if you call someone a nerd,

01:16:35.280 | I think it's a compliment.

01:16:36.120 | So my apologies to the non-nerds at Caltech.

01:16:38.360 | I think there's one or two of you.

01:16:39.800 | And for the nerdy ones of you at Caltech, you're welcome.

01:16:43.720 | They videotaped the behaviors of these faculty

01:16:46.080 | and students and staff.

01:16:47.280 | And what they found is that people follow trajectories

01:16:51.000 | from their car that are remarkably stereotyped.

01:16:53.680 | First of all, they tend to park always in the same spot

01:16:56.720 | if they can.

01:16:57.880 | They tend to get out of their car, of course,

01:16:59.280 | 'cause they're on the driver's side

01:17:00.200 | or passenger side in the same place.

01:17:02.040 | They turn and pivot their body

01:17:03.920 | at approximately the same rate every day.

01:17:05.580 | They close the door, they put their bag on their shoulder

01:17:08.500 | or across their chest or however it is that they carry,

01:17:10.520 | their briefcase or whatever it is.

01:17:11.900 | And they follow trajectories onto campus

01:17:15.100 | that are so stereotyped that you'd wonder

01:17:17.540 | if you just trace line after line after line,

01:17:19.500 | what you'd find is that every day is almost exactly the same

01:17:23.680 | and you do this too.

01:17:24.900 | You don't realize it because if you're being videotaped

01:17:27.900 | when this kind of behavior, it's not being released to you,

01:17:30.080 | but your behaviors are so stereotyped to the point

01:17:33.160 | where if you were to see them laid out in front of you

01:17:35.400 | in kind of diagrammatic format of the lines

01:17:38.060 | and the trajectories that you follow throughout the day,

01:17:40.380 | the lifting of your mug

01:17:41.600 | and how frequently you drink each hour,

01:17:43.600 | you would be amazed and probably a little bit scared

01:17:47.760 | by how much of a robot we all are.

01:17:51.280 | Now, that robotic aspect of our neural circuitry is vital

01:17:54.680 | because it's what allows us to think about other things

01:17:56.960 | and do other things and drive other behaviors.

01:17:59.800 | But the work of Dr. Steinglass and colleagues showed

01:18:03.040 | that in the case of the anorexic,

01:18:05.260 | those habits are exactly the place

01:18:07.960 | where things start to go awry

01:18:09.960 | and that drive this very dysfunctional under eating behavior

01:18:13.700 | that sadly often leads to death

01:18:16.120 | or certainly bad medical outcomes.

01:18:18.560 | And it turns out that the brain areas associated

01:18:21.620 | with habit formation and execution

01:18:24.240 | are the best point of intervention.

01:18:26.600 | So what Dr. Steinglass and colleagues did

01:18:28.880 | is they took anorexics and they of course had control groups

01:18:32.960 | and they put them in an fMRI scanner,

01:18:36.180 | which are these brain scanners that allow you to evaluate

01:18:39.020 | which brain areas are active during particular tasks.

01:18:42.400 | And because when you're in one of those scanners,

01:18:44.240 | you're actually, I've actually been in one of these things,

01:18:47.180 | you're biting down on a bite bar and you're most of the time

01:18:50.440 | in most all of these scanners, you're immobile.

01:18:52.520 | So you're looking at things on a TV screen.

01:18:54.100 | Sometimes you can press buttons to select choices

01:18:56.940 | and so forth, but you can't really eat within those things.

01:19:00.640 | What they found was that reward-based decision-making,

01:19:05.640 | the drive to pursue a particular food

01:19:08.880 | or the drive to perform a particular task,

01:19:12.440 | which is a lot of what we do throughout our day,

01:19:15.200 | that was controlled by a brain area

01:19:16.560 | called the ventromedial prefrontal cortex.

01:19:19.160 | Let me simplify a little bit of this,

01:19:20.780 | but I'm going to simplify it by giving you a little detail

01:19:23.480 | because it's the Huberman Lab podcast.

01:19:25.000 | And I believe in mechanism.

01:19:27.260 | Mechanism is the way that you get true understanding

01:19:29.660 | and that you can then be very quick

01:19:32.920 | and give overviews of things, but you need the mechanism.

01:19:36.220 | So you have reflexes and you have neural processes

01:19:41.220 | that include what are called duration path

01:19:45.920 | and outcome type processes.

01:19:47.740 | A duration path outcome type process,

01:19:49.860 | we can shorten with DPO.

01:19:52.100 | DPO is for all types of goal-related behaviors.

01:19:57.200 | So for instance, if you want to get a particular grade

01:20:00.060 | on an exam, you want to learn something,

01:20:01.500 | you want to complete a workout,

01:20:02.560 | you want to go to the grocery store and pick some stuff up

01:20:05.240 | and then head home, you're going to think duration.

01:20:08.260 | How long do I have?

01:20:09.180 | Okay, do I have 45 minutes to get to the store?

01:20:11.140 | How long does it take to get to the store?

01:20:12.560 | Path, which way am I going to drive there?

01:20:14.460 | Which way am I going to navigate through the grocery store?

01:20:17.020 | Outcome, was I able to get in and get the items I need

01:20:19.420 | and get home in time?

01:20:20.540 | Okay, DPO, duration path outcome.

01:20:22.620 | It's a very conscious process.

01:20:24.680 | You tend to take into account different criteria

01:20:27.020 | related to what's in,

01:20:28.600 | what's preventing you from accomplishing what you want to do

01:20:31.280 | and what's helping you or assisting you.

01:20:34.420 | So of course, as you get to the checkout line

01:20:35.900 | in the grocery store,

01:20:36.740 | you're going to select the shortest line, for instance.

01:20:38.160 | So that's all DPO stuff.

01:20:39.380 | It requires decision-making and it's reward-based.

01:20:42.740 | You use these DPO type processes in the short term

01:20:46.540 | to pick up groceries and pick a line at the grocery store

01:20:50.200 | and decide which trajectory to take home.

01:20:53.140 | And you use them for navigating long extended processes

01:20:56.880 | in life, trying to get a degree or raise children

01:20:59.060 | or get through a particularly challenging year, et cetera.

01:21:03.660 | So duration path outcome,

01:21:05.260 | and that entire process relies on your forebrain,

01:21:08.600 | this prefrontal cortex.

01:21:10.220 | The prefrontal cortex is what allows you

01:21:13.840 | to take information from memory,

01:21:15.500 | combine it with information about what's happening

01:21:18.240 | in the present context,

01:21:19.900 | and then to direct your behavior, your speech, et cetera,

01:21:24.220 | toward particular outcomes.

01:21:25.660 | And if all that sounds like a mouthful, it is,

01:21:29.240 | and it's very metabolically demanding.

01:21:30.960 | Decision-making is metabolically demanding.

01:21:33.200 | It takes effort, okay?

01:21:35.080 | Reflexes, on the other hand,

01:21:39.060 | don't involve the prefrontal cortex in the same way.

01:21:41.520 | Habits and reflexes, like once you know how to walk,

01:21:44.660 | you get up and you walk.

01:21:45.820 | You don't have to think about right foot, left foot,

01:21:47.520 | right foot, left foot, you just do it.

01:21:49.780 | That doesn't rely on prefrontal cortex.

01:21:51.800 | It's subconscious as it's sometimes called,

01:21:53.840 | but basically you don't have to use the parts of the brain

01:21:56.840 | that are involved in duration path

01:21:58.360 | and outcome type analysis, okay?

01:22:01.200 | So in this particular study,

01:22:03.320 | they examined brain activity in anorexics

01:22:06.900 | who are selecting different foods.

01:22:09.900 | And as I mentioned earlier,

01:22:10.900 | they have a hyperacuity or awareness

01:22:13.540 | of which foods contain more or less calories

01:22:16.700 | than other foods and what the fat content

01:22:19.080 | of particular foods is in particular, et cetera.

01:22:22.380 | They're doing all this while in a scanner,

01:22:25.260 | and then they look at what sorts of brain areas

01:22:28.300 | are active after that task is done.

01:22:31.660 | And what they found was really interesting.

01:22:33.620 | What they found was that the dorsolateral prefrontal cortex,

01:22:37.660 | not surprisingly, is involved in the decision-making

01:22:41.500 | and the evaluation of this food,

01:22:44.100 | which foods are going to be best to eat in this context,

01:22:47.820 | which foods are going to be appropriate

01:22:50.300 | for at least that anorexics framework

01:22:53.180 | about what's okay to eat and what's not okay to eat

01:22:55.580 | and how much.

01:22:56.800 | However, there are areas of the brain

01:23:00.420 | that were active after that decision-making process.

01:23:03.660 | And those are the brain areas that turn out

01:23:05.940 | to drive the habit of avoiding particular foods

01:23:09.380 | and approaching other foods.

01:23:11.460 | And in that case,

01:23:12.300 | it wasn't the dorsolateral prefrontal cortex.

01:23:14.740 | It was an area of the brain called the dorsolateral striatum.

01:23:18.220 | Now, the striatum is a big area in the brain.

01:23:20.940 | It's involved in a lot of different things.

01:23:23.020 | It includes areas like the caudate and putatum.

01:23:25.860 | And I just want to mention, as I throw out all these names,

01:23:27.780 | you do not need to remember the names

01:23:29.780 | of these different structures.

01:23:30.820 | They're just there if you are interested

01:23:32.220 | in that level of detail.

01:23:33.920 | But basically you have a brain area,

01:23:35.500 | and anorexics have a brain area that's involved

01:23:37.260 | in evaluating and decision-making around food.

01:23:39.720 | And then another brain area that's involved

01:23:42.120 | in the reflexive consumption of particular foods

01:23:45.900 | and the reflexive avoidance of other foods.

01:23:48.980 | If you remember way back at the beginning of the episode,

01:23:53.460 | I feel like that was a long time ago now,

01:23:55.280 | when we talked about how you have these sorts of processes

01:23:58.540 | in the brain, but there are always homeostatic

01:24:01.580 | and reward systems influencing this kind of thing.

01:24:05.340 | Well, in the brain of the anorexic,

01:24:08.860 | it turns out that the reward systems have been attached

01:24:12.720 | to the execution of habits

01:24:14.860 | in a way that is unhealthy for body weight,

01:24:18.220 | but at least from a purely neural circuit perspective,

01:24:21.600 | the reward is now given, this chemical reward in the brain,

01:24:25.540 | is given for avoiding particular foods

01:24:28.580 | and only approaching these very low calorie, low fat foods.

01:24:33.380 | So there really does seem to be a flip in the switch

01:24:37.280 | in the anorexic brain that rewards them internally.

01:24:40.460 | They feel good when they avoid certain foods

01:24:43.900 | and they approach others.

01:24:45.340 | So it's not a deprivation-based model

01:24:47.820 | where they are flagellating themselves or masochistic

01:24:51.660 | or actively avoiding food in order to punish themselves,

01:24:55.540 | which is interesting 'cause a lot of psychological theories

01:24:57.660 | support that idea.

01:24:59.080 | Rather, once this transitions into a set of habits,

01:25:04.080 | they are actually getting a sense of reward.

01:25:06.420 | They feel good, presumably from the release

01:25:08.500 | of a different neuromodulator called dopamine,

01:25:12.180 | by approaching foods that are low fat, low calorie content.

01:25:16.380 | And so their whole brain circuitry is skewed

01:25:19.220 | toward avoiding particular things

01:25:21.020 | and they actually are rewarded for that and they feel good.

01:25:24.600 | They feel better than if they were eating

01:25:26.760 | in a healthy weight-supporting way.

01:25:28.900 | Now, the dorsolateral striatum is a structure

01:25:33.420 | that we should think about in a little bit more depth.

01:25:36.060 | It's part of a set of circuits that are involved

01:25:38.780 | in what are called go/no-go tasks.

01:25:40.820 | And I don't want to go into this in a lot of detail

01:25:42.460 | right now because it would take us too far down

01:25:45.240 | the rabbit hole of neural circuitry.

01:25:47.320 | But basically, in terms of behaviors,

01:25:51.880 | we both have DPO-type behaviors,

01:25:55.340 | so decision-making, reward-based behaviors,

01:25:57.780 | and we have habits that we learn and we acquire

01:26:02.160 | and then we just start to execute reflexively.

01:26:04.460 | Things like walking, things like yawning when we're tired,

01:26:07.700 | things like taking a particular route through the parking lot.

01:26:11.120 | We learn that the first time we go to a given parking lot

01:26:13.620 | and walk into a building,

01:26:14.460 | but after that we tend to follow the exact same trajectory.

01:26:16.620 | It becomes very automatized.

01:26:18.820 | It's just like we just do it without thinking.

01:26:22.220 | Well, the go/no-go circuitry is another aspect

01:26:27.220 | of our behavior where we both have to select behaviors

01:26:30.640 | to perform and we have to select behaviors to suppress.

01:26:34.780 | And the anorexic brain seems to reward suppression

01:26:39.780 | of one set of behaviors, ingestion of high-calorie foods,

01:26:43.060 | and to reward focus or even hyper-focus

01:26:47.980 | and consumption of low-fat, low-calorie foods.

01:26:52.000 | So this homeostatic process that we learn about

01:26:54.560 | from like high school onward that, oh,

01:26:56.620 | everything in your body is designed

01:26:58.140 | to keep everything in balance.

01:26:59.680 | You stay awake for a certain amount of time,

01:27:01.240 | you want to sleep.

01:27:02.220 | You don't eat for a while,

01:27:03.140 | then you want to eat to maintain weight, right?

01:27:05.020 | You eat too much, then you want to eat less.

01:27:07.100 | Those systems are disrupted.

01:27:09.380 | And so what's so beautiful about this work

01:27:12.320 | from the Columbia group is that what it says is

01:27:17.260 | the place to intervene has to be the habit.

01:27:20.740 | This stuff has already passed through all the learning.

01:27:23.260 | It's passed through all the reward systems.

01:27:25.220 | It's clearly not being overrun

01:27:27.100 | by the homeostatic processes of the body.

01:27:28.900 | There's very little body fat.

01:27:30.400 | There's no leptin.

01:27:31.580 | Whatever neurons in the brain respond to leptin

01:27:33.340 | are starved for leptin.

01:27:35.540 | Periods have shut down, sperm production

01:27:37.360 | and testosterone is lowered, bone density is down.

01:27:40.240 | Clearly this is overriding all those homeostatic processes,

01:27:44.340 | all the signals that would say, eat, eat, eat.

01:27:47.220 | Those don't matter in the brain of the anorexic.

01:27:50.860 | The brain of the anorexic is just performing habits

01:27:53.740 | and they're being rewarded for it.

01:27:55.500 | So when you come along and say, look,

01:27:57.520 | you should really eat this whole pie or this whole pizza,

01:27:59.660 | you'll feel better.

01:28:00.700 | That's actually aversive to them.

01:28:02.540 | So since it appears to be a habit,

01:28:04.540 | a reflex that's perpetuating the anorexic phenotype,

01:28:08.660 | as we say in science,

01:28:09.560 | it's perpetuating anorexia in this individual

01:28:12.460 | and telling them about all this terrible stuff

01:28:14.980 | that's happening in their body won't work.

01:28:17.160 | Taking them away from all the images of thin people online,

01:28:20.660 | et cetera, that's not going to work.

01:28:22.580 | What's going to work?

01:28:24.000 | What's going to work is intervening in the neural circuitry

01:28:27.340 | that's related to the habit itself.

01:28:30.340 | And it turns out that there are ways to do that.

01:28:32.420 | So how do you break a habit?

01:28:33.820 | How do you rewire the brain circuitry

01:28:35.600 | that's literally causing a reflex?

01:28:37.560 | And in this case,

01:28:38.400 | causing a reflex that is killing the individual,

01:28:41.620 | or at least leading to very bad health outcomes.

01:28:44.700 | The way that you do that is through a cognitive mechanism

01:28:49.660 | where you teach the individual

01:28:51.500 | what is leading up to the habit.

01:28:53.780 | This is a little bit similar to the way

01:28:55.260 | that somebody who suffers from addiction

01:28:58.100 | starts to put in different constraint type behaviors.

01:29:01.300 | Constraint type behaviors are the sorts of things

01:29:04.100 | like where the alcoholic will call a hotel ahead of time

01:29:07.220 | and say, listen, I want the minibar taken out of the room.

01:29:10.760 | I don't want a television in the room, et cetera,

01:29:12.660 | constraint type behaviors.

01:29:14.140 | Those are really ways of keeping oneself from the temptation.

01:29:18.660 | But with these habits,

01:29:19.980 | they work at such a subconscious level

01:29:22.300 | that what seems to work best is a combination

01:29:25.740 | of teaching the individual about their internal state

01:29:29.920 | and how to register their internal state,

01:29:31.660 | what we call interoception,

01:29:32.860 | this ability to perceive your internal state,

01:29:35.460 | so that they can start to learn

01:29:38.020 | to associate the interactions with different types of food

01:29:41.720 | with the sorts of cues that are occurring within their body,

01:29:44.820 | quickening of heart rate,

01:29:46.700 | hyperacuity of focus that we talked about earlier.

01:29:49.780 | Once they start to be able to notice

01:29:51.460 | that those things are happening,

01:29:53.060 | then they can start to intervene.

01:29:54.980 | So let's talk about what those things are

01:29:57.340 | that lead into a habit,

01:29:59.140 | because those turn out to be the exact points of entry

01:30:02.220 | for changing and eliminating and rewiring habits

01:30:05.960 | toward more healthy behaviors.

01:30:07.500 | And I should highlight that this isn't just about

01:30:09.940 | rewiring habits for sake of the anorexic.

01:30:12.300 | These are also the same types of mechanisms

01:30:14.540 | that one would want to incorporate

01:30:16.540 | in order to rewire any habit of any kind.

01:30:19.380 | There are two main features of thinking

01:30:21.480 | that go into the sorts of habits that anorexics execute.

01:30:25.300 | The first is something called weak central coherence.

01:30:29.440 | Weak central coherence is essentially an inability

01:30:32.440 | to see the forest through the trees.

01:30:34.960 | It's a hyperacuity and focus on details

01:30:37.960 | within a given environment.

01:30:39.000 | And there's actually an interesting probe test for anorexia

01:30:42.620 | that involves something akin

01:30:44.400 | to kind of a where's Waldo type puzzle,

01:30:47.280 | where an image is put up.

01:30:50.100 | The one that I saw was one in which there's a big array

01:30:52.920 | of coffee beans.

01:30:54.060 | Actually, they're all brown coffee beans.

01:30:55.620 | And your job is to identify

01:30:58.660 | where in that array of coffee beans there's a face.

01:31:01.500 | And indeed there's a face embedded in there.

01:31:03.660 | It looks a little bit like a coffee bean,

01:31:04.940 | but once you see it, you realize it's a face,

01:31:06.560 | not a coffee bean.

01:31:08.020 | And it becomes very hard to not notice the face after that.

01:31:11.920 | Anorexics are very good at identifying the face.

01:31:17.220 | They find it much faster than do non-anorexics,

01:31:21.160 | which is really interesting, right?

01:31:22.920 | They somehow are able to hone in on details

01:31:25.240 | and find those details and fixate on those details.

01:31:28.960 | Now, eventually most, if not all people find the face.

01:31:32.320 | But once you do, what you will find

01:31:35.040 | and what everyone finds is that you can't unfind the face.

01:31:37.640 | It just jumps out.

01:31:38.500 | So what essentially you've lost is the ability

01:31:40.520 | to see the whole picture because there's some detail

01:31:43.680 | within that picture that you're obsessed by.

01:31:46.160 | So this has kind of elements

01:31:47.440 | of obsessive compulsive disorder,

01:31:48.840 | but it's not really obsessive compulsive disorder per se.

01:31:52.160 | So we call that weak central coherence.

01:31:54.600 | It's a hyper acuity on one particular feature.

01:31:58.500 | You miss the big picture.

01:32:00.200 | The other is a challenge in set shifting

01:32:02.200 | that once you identify something

01:32:04.020 | that's of particular interest

01:32:06.040 | and that's driving some sort of reward for the anorexic,

01:32:09.840 | that would be identifying the high fat foods

01:32:12.240 | or identifying the one food on the table

01:32:14.280 | that one could eat without anyone hopefully noticing

01:32:17.200 | that they're eating just the green beans

01:32:19.640 | and not touching any of the other food.

01:32:21.400 | If you ever had a meal with an anorexic,

01:32:23.640 | you might be familiar with this.

01:32:25.400 | It's kind of uncomfortable to be around actually.

01:32:27.840 | They go through a lot of elaborate procedures

01:32:29.700 | to kind of hide food, to they'll sometimes even chew food,

01:32:32.760 | hold it in their mouth and then go to the bathroom

01:32:34.600 | and discard it.

01:32:35.440 | Things very elaborate, very troubling types of things

01:32:37.440 | to hear about and to be around.

01:32:38.960 | But you'll notice that they push food

01:32:40.320 | around their plate a lot.

01:32:41.400 | They become masterful actually

01:32:43.280 | at trying to keep people's awareness

01:32:45.640 | away from what they're doing,

01:32:46.720 | which is to home in on these low fat, low calorie foods.

01:32:50.280 | And they can't seem to set shift.

01:32:51.780 | They can't just relax and enjoy the meal

01:32:54.100 | because the meal for them is essentially

01:32:56.820 | like this where's Waldo

01:32:58.180 | or find the face in the coffee bean task.

01:33:00.080 | They're constantly monitoring

01:33:02.300 | how much people are observing them

01:33:04.040 | and trying to navigate this,

01:33:05.700 | what would otherwise be a really pleasant circumstance

01:33:08.240 | for most people.

01:33:09.080 | They're trying to navigate through this

01:33:10.440 | because remember for them,

01:33:12.060 | the reward is in the avoidance of certain things

01:33:14.900 | and the acquiring of only the foods

01:33:17.380 | that their brain rewards them for

01:33:19.120 | because those are the foods that have been pre-selected

01:33:21.220 | and are now habit.

01:33:22.580 | What's amazing and frankly also important

01:33:27.200 | are these findings that once you teach anorexics

01:33:29.760 | what's happening to them, that they're doing this,

01:33:33.100 | they are able to intervene.

01:33:35.000 | Now they need support, right?

01:33:37.200 | And another form of therapy that seems to work well

01:33:40.280 | for anorexics that ideally is combined

01:33:43.300 | with this habit rewiring is a family-based model.

01:33:47.960 | Family-based models are starting to surface a lot now

01:33:50.560 | in various therapy settings.

01:33:52.860 | Therapy-based models in short are basically

01:33:55.340 | where the entire family is made aware

01:33:57.860 | of the individual's challenges

01:33:59.480 | with a particular eating disorder or other disorder.

01:34:01.980 | And in understanding some of the biology

01:34:04.420 | and psychology around it,

01:34:05.980 | they stop condemning the individual.

01:34:08.380 | They start to support that individual

01:34:10.080 | through queuing them towards their own habits

01:34:12.940 | that they observe.

01:34:13.780 | They give them some autonomy.

01:34:14.920 | They realize that none of this changes overnight,

01:34:17.180 | but they're taught about things like neuroplasticity

01:34:19.540 | and the ability to change one's brain

01:34:21.120 | in response to experience.

01:34:22.420 | And so there's a whole internal support network.

01:34:25.520 | Now for people that live alone,

01:34:27.360 | this isn't available to them.

01:34:28.620 | This isn't the kind of thing

01:34:29.460 | that you share with your coworkers.

01:34:30.540 | You might involve a close friend or a spouse,

01:34:33.500 | but it's not the sort of thing that people

01:34:35.740 | that don't live in a family context

01:34:38.540 | can really benefit from.

01:34:40.400 | All of these things fall under the umbrella

01:34:43.040 | of cognitive behavioral therapy.

01:34:44.900 | And I should mention that cognitive behavioral therapies

01:34:47.300 | are often done in conjunction with pharmacologic therapies.

01:34:51.000 | I think that there's this idea out there

01:34:53.120 | that it's either or when often it's both.

01:34:56.080 | So cognitive behavioral therapies are often combined

01:34:58.440 | with this habit recognition and rewiring approach,

01:35:02.780 | which is starting to become more and more common.

01:35:04.920 | And I think the data on it look really good

01:35:07.480 | that especially when individuals are taught this early

01:35:11.800 | in adolescence, that there are positive outcomes over time.

01:35:16.500 | The relapse rate of anorexia is quite high.

01:35:19.020 | It's about 50% of individuals will relapse at some point,

01:35:21.820 | often triggered by a stressful life circumstance.

01:35:24.360 | But the combination of cognitive behavioral therapy

01:35:27.540 | that includes this family model,

01:35:29.260 | or at least habit reformation seems to be fairly effective.

01:35:33.380 | And at present might be the most effective treatment.

01:35:36.060 | Now there are additional treatments starting to surface,

01:35:38.580 | and that takes us into the realm of chemical treatments

01:35:41.880 | for anorexia.

01:35:42.740 | And I just want to mention that there are clinical trials,

01:35:46.660 | meaning legal clinical trials being done

01:35:48.760 | at Johns Hopkins School of Medicine

01:35:50.040 | by Matthew Johnson and others,

01:35:51.840 | exploring how drugs like MDMA,

01:35:55.500 | which increases dopamine and serotonin to very high levels,

01:35:58.880 | or psilocybin, so-called magic mushrooms,

01:36:01.960 | which increases serotonin and other compounds

01:36:04.500 | to very high levels,

01:36:05.980 | within the confines of a professionally supported

01:36:09.540 | therapeutic environment can help people rewire their brain

01:36:13.380 | such that they can get relief from major depression

01:36:15.980 | and various forms of trauma.

01:36:17.380 | And now eating disorders are also being explored

01:36:20.900 | in the context of MDMA and psilocybin clinical trials.

01:36:24.960 | I do want to emphasize that those are clinical trials,

01:36:28.660 | that those compounds are not yet legal.

01:36:30.700 | And in many cases, most cases, they are still illegal.

01:36:34.980 | I do not think that they should be explored

01:36:37.860 | without a properly trained medical doctor,

01:36:42.160 | that the clinical trials are essential to complete

01:36:44.580 | before one explores those compounds in particular,

01:36:48.500 | because lately I get a lot of emails about these compounds,

01:36:51.420 | people telling me that they've had amazing experiences

01:36:53.940 | and relief from various things, not just eating disorders,

01:36:56.540 | but depression, et cetera.

01:36:58.200 | However, I get an equal number of emails from people saying

01:37:02.540 | that they worked with some self-appointed guide.

01:37:05.660 | This would be outside the clinical trials

01:37:07.280 | I was referring to.

01:37:08.500 | And they are now experiencing chronic visual snow.

01:37:12.140 | They're getting genuine visual field deficits.

01:37:14.960 | They are having tics that they never had before.

01:37:18.020 | They have chronic insomnia.

01:37:19.260 | So I'm not passing judgment on any of these compounds

01:37:22.820 | or the people that are doing this sort of thing.

01:37:24.460 | I just want to see the clinical data.

01:37:26.720 | And I do believe that we should wait

01:37:28.380 | until these clinical trials are done

01:37:30.340 | before people start approaching this stuff.

01:37:32.540 | And that's because they are serious compounds.

01:37:36.660 | They can open plasticity, but whether or not they work,

01:37:40.180 | quote unquote, for different types of eating disorders

01:37:43.700 | or depression and trauma, the data are looking promising,

01:37:47.780 | but that the clinical trials are still not done.

01:37:50.140 | And I know a number of people are going out of the US

01:37:52.360 | and into other countries where this stuff is being done

01:37:55.020 | more regularly.

01:37:55.940 | And there too, I've gotten reports back

01:37:58.220 | of people doing so-called Ibogaine treatments.

01:38:00.540 | Some of you who are familiar with eating disorders

01:38:02.900 | will immediately be asking, well, what about Ibogaine?

01:38:05.300 | Does it work? Does it work?

01:38:06.500 | Well, the clinical trials in this country are not complete.

01:38:09.540 | I've heard evidence direct.

01:38:13.300 | I've heard directly from people who have benefited

01:38:16.940 | from the sorts of things for treatment of eating disorders.

01:38:19.420 | But I've also heard of people that have developed

01:38:21.740 | chronic seizure disorders from pursuing things like Ibogaine

01:38:25.620 | for the treatment of eating disorders.

01:38:28.440 | So again, I'm not passing judgment.

01:38:29.860 | I would just like to see more data.

01:38:31.700 | And it's very important that the aspects of safety

01:38:35.880 | be in place.

01:38:36.720 | So this is definitely not something to get renegade about.

01:38:39.780 | So it appears that once anorexia is established,

01:38:42.940 | that habit breaking through self-awareness

01:38:45.940 | of what the habits are is going to be a primary entry point.

01:38:50.520 | That might seem kind of trivial.

01:38:52.540 | You might say, well,

01:38:53.380 | couldn't you have just told us that in one sentence?

01:38:55.060 | But I want to return us to this model

01:38:58.220 | about homeostatic processes, reward processes, et cetera.

01:39:01.820 | That leads us to a place where the short answer is no.

01:39:06.220 | You can't simply say break the habit.

01:39:09.100 | An individual needs to be informed

01:39:11.260 | about where that habit comes from.

01:39:13.060 | And the fact that what currently seems like a rewarded habit

01:39:17.660 | should actually be a punished habit.

01:39:20.240 | Now, I don't mean by actual punishment,

01:39:22.520 | but what I mean is within the brain,

01:39:25.020 | there's been a switch and the anorexic

01:39:27.380 | needs to learn that there's been a switch

01:39:29.180 | such that what should be rewarding is now punished

01:39:32.940 | and what should be punished, starvation is now rewarded.

01:39:35.900 | The beauty of being a human being

01:39:38.880 | is that knowledge of knowledge

01:39:42.260 | can allow you to make better decisions.

01:39:44.560 | I'll say that again.

01:39:46.540 | The beauty of being a human being

01:39:47.740 | is that knowledge of knowledge

01:39:49.100 | can allow you to make better decisions.

01:39:50.980 | Now, of course, when we are anxious,

01:39:53.760 | when we are tired, when we are intoxicated,

01:39:58.360 | we have less access to that ability

01:40:00.940 | to use knowledge of knowledge to intervene.

01:40:03.720 | The anorexic will often do things

01:40:05.740 | that are in keeping with their habits,

01:40:07.700 | such as overexercising.

01:40:09.180 | This is a area that anyone who's treated anorexics

01:40:12.540 | or interacted with anorexics is well aware of

01:40:15.120 | that they are constantly moving.

01:40:17.220 | They're constantly on the treadmill.

01:40:18.540 | They're constantly running.

01:40:19.620 | They always want to be moving and burning calories

01:40:22.180 | so that they can feel okay about interacting with food

01:40:25.140 | or because they have the distorted body image.

01:40:27.960 | Well, does breaking a habit mean

01:40:30.920 | that they should stop moving around and exercising?

01:40:33.340 | No, not necessarily.

01:40:34.820 | There's some really interesting studies

01:40:36.300 | that show that shifting anorexics towards activities

01:40:41.300 | that, for instance, build muscle resistance training

01:40:44.920 | and allow them to eat a bit more food

01:40:47.900 | without necessarily losing weight,

01:40:51.660 | but rather to put more muscle on their body

01:40:54.740 | can actually be beneficial.

01:40:55.860 | Now, I'm not talking about anorexics becoming bodybuilders.

01:40:58.740 | There's a whole body dysmorphia associated

01:41:00.420 | with bodybuilding.

01:41:01.620 | But certain forms of exercise are just catabolic,

01:41:04.820 | meaning they break down the amount of muscle.

01:41:06.500 | They reduce body weight overall.

01:41:08.860 | Other types of exercises like resistance training

01:41:11.980 | are anabolic.

01:41:13.460 | They allow muscle to be put on.

01:41:15.340 | And there are some interesting studies, not a lot,

01:41:18.220 | but some interesting studies trying to encourage anorexics

01:41:21.700 | not to stop exercising, but rather to stop exercising

01:41:25.160 | in this neurotic catabolic way of breaking oneself down,

01:41:28.880 | but rather getting them shifted toward breaking habits

01:41:32.580 | of only approaching low calorie, low fat foods,

01:41:34.840 | while also encouraging them to embark

01:41:36.940 | on resistance training and to start to learn

01:41:40.340 | and reward the relationship between exercise

01:41:43.340 | for sake of making one's body strong,

01:41:45.520 | including the bones, not just the muscles,

01:41:47.640 | but the bones, which is important, especially in anorexics.

01:41:50.600 | And then to see food as a way to nourish that process,

01:41:53.820 | to building a body that could be of the stable weight,

01:41:56.940 | hopefully once the anorexic is of a healthy weight

01:42:00.000 | that they're maintaining that weight,

01:42:01.680 | but that they don't have to constantly be on this treadmill,

01:42:04.300 | no pun intended, of balancing whatever food intake

01:42:08.000 | they have with activity.

01:42:09.500 | And along the lines of that,

01:42:12.540 | during the episode on fat loss and metabolism as well,

01:42:15.400 | I talked about this neat and non-exercise

01:42:18.740 | induced thermogenesis, where people who tend to be thin

01:42:22.460 | tend to bounce around a lot, they're kind of fidgety,

01:42:24.620 | and that burns thousands of calories a day,

01:42:26.640 | anywhere from 800 to 2000 calories a day.

01:42:29.180 | Now that can be beneficial for the folks

01:42:30.940 | that are overweight and have a healthy mindset about food,

01:42:33.940 | but are trying to lose weight.

01:42:35.400 | And it turns out that by literally fidgeting

01:42:39.500 | and bouncing around like this is why I'm doing this,

01:42:40.900 | it looks ridiculous, you actually burn a lot of body fat

01:42:44.360 | and calories that way,

01:42:45.820 | provided you're in a caloric deficit, you burn body fat,

01:42:48.660 | because body fat is not just a passive tissue,

01:42:50.620 | it actually receives input from neurons

01:42:52.780 | that release noradrenaline and adrenaline.

01:42:54.980 | And this neat has been described for several decades now,

01:42:59.220 | and it actually is a pretty terrific way

01:43:00.860 | to burn off more calories.

01:43:02.220 | So with the anorexic, you actually want to encourage them

01:43:06.520 | to not constantly be trying to burn off calories.

01:43:09.580 | That can be very challenging.

01:43:10.620 | So shifting them toward activities

01:43:13.100 | like weight-bearing activities or resistance training

01:43:15.860 | that promote this more anabolic type of relationship

01:43:18.900 | to activity as opposed to catabolic can be beneficial.

01:43:22.100 | Before we move on to talking about bulimia

01:43:24.180 | and some related disorders,

01:43:25.640 | I want to talk about an aspect of anorexia

01:43:27.460 | that's very interesting, quite troubling in fact,

01:43:30.800 | but that has received a lot of attention

01:43:33.420 | and that's the distorted self image.

01:43:38.080 | Now, in the episode on depression,

01:43:40.880 | we talked about a very powerful aspect of major depression,

01:43:45.680 | which is this anti-self confabulation

01:43:47.680 | that people who are depressed seem to genuinely believe

01:43:51.400 | and even confabulate about the fact

01:43:53.240 | that they are performing poorly in life

01:43:55.080 | and that they are no good or worthless, et cetera.

01:43:58.080 | It's literally a lie that they believe

01:44:00.640 | and their statements and their feelings

01:44:02.980 | and their behaviors start to reflect that lie.

01:44:05.540 | They're not conscious of it.

01:44:06.460 | That's why we call it a confabulation.

01:44:09.840 | Anorexics often will see themselves as overweight

01:44:14.840 | or imperfect in ways that are of an obsession for them.

01:44:18.780 | They'll think, oh, you know,

01:44:19.620 | their arms are a little bit fat, you know,

01:44:22.320 | or, you know, the contour of their face makes,

01:44:24.900 | they don't like the pictures of themselves or they,

01:44:28.040 | what I'm describing here is actually pretty typical behavior

01:44:30.640 | of a lot of people.

01:44:31.720 | I mean, how many people do you know

01:44:32.720 | that after you take a picture of them,

01:44:34.160 | they say, can I see the picture?

01:44:35.400 | And then they tell you that you have to throw it away.

01:44:37.560 | That doesn't necessarily mean they're anorexic

01:44:39.400 | or they're suffering from some sort of disorder.

01:44:41.360 | That just means that they're a human being

01:44:42.760 | that cares about how they appear in the world.

01:44:45.560 | We're not here to judge that.

01:44:46.900 | In the case of the anorexic,

01:44:48.920 | the problem seems to be that they have a genuine distortion

01:44:53.080 | of their self-image so much so

01:44:55.860 | that they don't actually see themselves accurately.

01:44:59.180 | Their visual perceptions are off.

01:45:01.840 | And the reason we know this

01:45:03.120 | or it's because of some really important

01:45:05.080 | and beautiful studies that were done

01:45:07.480 | in my colleague Jeremy Bailenson's lab at Stanford,

01:45:10.000 | he's in the Department of Communications.

01:45:11.680 | He's actually collaborated with Dr. Halpern

01:45:13.880 | that I mentioned earlier.

01:45:15.160 | What's really interesting about these studies

01:45:16.720 | is they give us a window into the perceptual defect

01:45:19.800 | that anorexics have.

01:45:21.600 | I've actually done one of these experiments.

01:45:23.440 | I'm fortunate to not be anorexic,

01:45:25.020 | but I've done some work with the VR lab over there.

01:45:27.080 | And what you get to do is you get to adjust

01:45:29.320 | this avatar of yourself to the point where you think

01:45:31.720 | it's as accurate as it could possibly be.

01:45:34.640 | And anorexics really distort this avatar.

01:45:39.220 | In other words, they create this serious mismatch

01:45:42.160 | between their perception of themselves and the reality.

01:45:44.780 | So indeed it does seem to be the case.

01:45:47.140 | Now what's relieving, or I should say what's encouraging

01:45:51.360 | about some of the therapies that we talked about before,

01:45:53.720 | the family-based model, the cognitive behavioral treatments,

01:45:57.660 | yes, and the drug treatments as well,

01:45:59.600 | but this habit intervention model is that

01:46:02.880 | as one starts to shift those things,

01:46:05.680 | it does appear that the perception of self seems to follow,

01:46:09.600 | that the perception of self seems to shift along

01:46:12.520 | with the change in habits.

01:46:14.320 | And that's a relief, at least I find that reassuring

01:46:17.320 | because changing one's perception is actually very hard.

01:46:21.700 | As somebody who's worked almost his entire career

01:46:24.000 | on visual perception and related things,

01:46:26.480 | the perceptual apparatus of the brain

01:46:28.960 | are not very amenable to neuroplasticity.

01:46:32.420 | I mean, they don't change that easily.

01:46:34.560 | Whereas it appears that the circuitry

01:46:37.060 | that's related to habit formation and decision-making

01:46:39.480 | and the reward circuitry, that stuff can be rewired.

01:46:42.920 | And so anorexics, as they progress

01:46:45.000 | out of their anorexic state into one

01:46:47.920 | which they are intervening in their reflexes,

01:46:51.240 | gaining better habits around food,

01:46:52.840 | eating more accurately, assessing foods and environments

01:46:57.840 | that they're in related to food,

01:47:00.420 | as they change their behavior

01:47:01.620 | and they start to put on healthy weight,

01:47:03.100 | maybe they're also doing the sorts of exercises

01:47:04.920 | that allow them to put on healthy weight

01:47:06.780 | and avoiding kind of extreme exercises of catabolism

01:47:10.160 | and breaking themselves down.

01:47:11.560 | They also managed to somehow,

01:47:14.280 | just as a consequence of all that,

01:47:15.920 | rewire their perception of self.

01:47:18.400 | So it doesn't seem that trying to tell someone,

01:47:20.600 | oh my gosh, you're so thin, you really need to eat,

01:47:23.360 | that doesn't seem to work.

01:47:24.880 | They just don't see themselves the same way

01:47:27.660 | that you see them.

01:47:28.720 | And so I offer that as a point of consideration

01:47:31.560 | if you know someone that's anorexic,

01:47:32.900 | or if you look at an anorexic and you think,

01:47:34.980 | how is it that they are still critical of the small,

01:47:38.740 | even non-existent amount of body fat

01:47:40.580 | on their triceps or something, how is that?

01:47:42.920 | Well, it's literally that their brain,

01:47:45.340 | as it relates to perceptions,

01:47:46.720 | visual perceptions in particular,

01:47:48.900 | that they're completely off.

01:47:50.120 | And fortunately by changing habits,

01:47:52.100 | you rewire those circuits as well.

01:47:54.200 | Okay, so let's talk about bulimia,

01:47:56.640 | which is overeating and then purging,

01:48:00.800 | typically by self-induced vomiting

01:48:03.080 | or by ingestion of laxatives,

01:48:05.160 | sometimes also in concert with people taking stimulants

01:48:09.400 | and fat burners and over-ingestion of stimulants

01:48:12.440 | to try and burn off more energy.

01:48:14.600 | And then we'll also talk about binge eating disorder,

01:48:16.800 | which has a lot of the same features as bulimia,

01:48:19.960 | but typically no purging.

01:48:22.020 | I'm not going to list off all the clinical criteria

01:48:26.420 | that would allow someone to be diagnosed

01:48:29.440 | as bulimic or binge eating disorder.

01:48:32.420 | But the general features are that they ingest

01:48:34.760 | far more calories than they need,

01:48:37.420 | anywhere from 10 to 30 times their daily caloric intake,

01:48:42.320 | oftentimes within a two hour period,

01:48:45.180 | which is just a staggering amount of food

01:48:48.360 | and nutrients in a short period of time.

01:48:50.800 | Oftentimes they're overriding those mechanical signals

01:48:53.480 | from the body that they're full.

01:48:55.920 | It's a really troubling thing to think about,

01:48:58.760 | but people are literally gorging themselves with food.

01:49:01.960 | This looks a lot like a laboratory animal

01:49:05.120 | that has these AGRP neurons stimulated,

01:49:07.620 | these neurons that will eat

01:49:08.640 | until they almost burst or burst.

01:49:11.420 | So you wonder, is it these AGRP neurons that are active?

01:49:13.880 | Almost certainly, yes, that they're involved.

01:49:16.240 | Although I don't think that that's going to be

01:49:17.880 | the major point of intervention,

01:49:20.320 | that we're going to talk about other types of interventions.

01:49:23.720 | There are a number of clinical criteria.

01:49:25.360 | For instance, if somebody has one of these binges once a year

01:49:29.440 | does that make them bulimic?

01:49:30.800 | Technically, no, but I certainly don't recommend

01:49:34.920 | people do this.

01:49:36.540 | If you are one of these people

01:49:38.520 | who has so-called cheat days, right?

01:49:40.680 | Some of you may be familiar with cheat days.

01:49:43.040 | I think they're a little less common now,

01:49:44.320 | but the idea is you eat clean for six days

01:49:47.600 | or five days a week or two weeks,

01:49:49.440 | and then you have a so-called cheat day

01:49:50.600 | where you just kind of go wild and eat whatever you want

01:49:52.980 | and whatever volumes is that bulimia

01:49:55.760 | has some of the contour of bulimia.

01:49:58.320 | If you're vomiting afterwards or binge eating disorder,

01:50:00.760 | if you're not, does it constitute full-blown bulimia

01:50:03.740 | or binge eating disorder?

01:50:04.860 | It's pretty hard to say.

01:50:06.660 | The criteria that were described to me

01:50:08.180 | is that if somebody is doing this at least once a month

01:50:11.280 | over a period of anywhere from two to three months,

01:50:13.820 | then it likely would qualify.

01:50:16.180 | And I certainly know people who do these cheat days

01:50:19.020 | and by those criteria,

01:50:21.280 | they have something like binge eating disorder.

01:50:23.800 | But in general, one of the hallmark features

01:50:26.780 | of bulimia and binge eating disorder

01:50:28.640 | is that people are unable to control their eating.

01:50:31.880 | They're just simply,

01:50:32.780 | they're not making the decision to have a cheat day.

01:50:35.420 | They're not making the decision to overeat.

01:50:37.880 | They are simply driven from the inside

01:50:42.180 | without question by way of neural circuitry.

01:50:45.520 | They are driven from the inside

01:50:47.780 | to ingest far more food than they need

01:50:51.260 | and in some cases than they would want to eat.

01:50:54.140 | So it's a lot like the habit

01:50:56.460 | that we described for anorexia.

01:50:58.640 | It's almost like it's turned into a reflex

01:51:00.740 | once they get going.

01:51:02.080 | All the homeostatic signals are being overridden.

01:51:05.300 | All the signals from the body, the leptin,

01:51:08.300 | the insulin, the glucose,

01:51:10.180 | all that stuff is cosmically sky high.

01:51:12.240 | And yet they're just what the nerds call hyperphagic.

01:51:17.360 | They're just eating like crazy.

01:51:18.900 | So what's going on there?

01:51:21.320 | Well, there've been a lot of ideas, you know,

01:51:24.460 | about why this arises.

01:51:26.500 | There's the so-called thyroid hormone hypothesis.

01:51:30.500 | That one's a tricky one.

01:51:31.760 | It turns out that cortisol

01:51:33.680 | and thyroid hormone concentrations vary

01:51:36.540 | according to when the binge purge happened.

01:51:40.300 | So there were some studies

01:51:41.440 | that looked at thyroid hormone levels

01:51:43.820 | and they found elevated thyroid hormone levels.

01:51:47.080 | Thyroid hormone is involved in metabolism

01:51:49.420 | and not just the burning of energy,

01:51:51.920 | but the use of energy in converting it

01:51:54.780 | to different tissues of the body,

01:51:56.220 | cartilage, bone, fat, and muscle, et cetera.

01:51:59.560 | Did a whole episode on thyroid and growth hormone,

01:52:02.580 | by the way, if you're interested

01:52:03.660 | in learning more about thyroid hormone.

01:52:05.660 | But thyroid hormone can also be depleted

01:52:10.300 | at other phases of the binge purge cycle.

01:52:12.740 | Now, without listing off all the terrible things

01:52:15.940 | that happen with this binge purge cycle,

01:52:18.200 | there are a number of things

01:52:19.280 | that are really worth pointing out.

01:52:21.400 | One is that the vomiting itself, the use of laxatives,

01:52:25.220 | that can cause severe disruption to the mucosal lining,

01:52:29.160 | the mucus lining of the digestive tract,

01:52:31.000 | can severely disrupt the gut microbiome.

01:52:34.100 | It can cause all sorts of even ulceration of the esophagus

01:52:39.100 | and just really terrible stuff.

01:52:41.120 | There's a lot of shame associated with bulimia,

01:52:45.700 | oftentimes because people are vomiting

01:52:48.580 | and it's hard to hide that vomiting behavior.

01:52:52.000 | People are aware of it.

01:52:53.060 | There's some social isolation.

01:52:54.820 | So you recall from the beginning,

01:52:55.860 | it does not appear that sexual trauma

01:52:58.380 | is a prerequisite for bulimia,

01:53:00.580 | although sometimes it can occur.

01:53:02.340 | The hallmark feature of bulimia

01:53:04.060 | that distinguishes it from anorexia,

01:53:06.780 | aside from the fact that it's overeating

01:53:08.280 | as opposed to undereating,

01:53:09.840 | is a lack of what they call inhibitory control.

01:53:12.780 | And that might come as no surprise.

01:53:15.100 | But first of all, the bulimic, unlike the anorexic,

01:53:20.100 | is hyper impulsive

01:53:23.780 | and oftentimes has other types of impulse behaviors.

01:53:26.620 | They might have a little bit of alcohol

01:53:28.560 | and then start to eat like crazy,

01:53:30.520 | whereas normally they're very restrictive.

01:53:32.020 | That's a common feature of bulimia.

01:53:34.800 | Sometimes they over ingest alcohol during these binges.

01:53:38.140 | Sometimes they are sexually promiscuous, not always,

01:53:41.940 | but it's a general issue with satiety

01:53:45.140 | once they start eating and with impulse control generally.

01:53:48.740 | And for that reason,

01:53:50.380 | many of the treatments that you see for bulimia

01:53:52.380 | and binge eating disorder are the sorts of treatments

01:53:55.140 | that don't seem to work so well,

01:53:57.500 | or at least most of the time for anorexia.

01:54:00.140 | So the drugs that increase the neuromodulator serotonin,

01:54:04.160 | for instance, fluoxetine,

01:54:06.860 | also called Prozac, Paxil, et cetera,

01:54:09.580 | those things oftentimes can be effective in bulimia.

01:54:13.860 | Some of the drugs that are used to treat

01:54:15.540 | attention deficit hyperactivity disorder and ADD,

01:54:17.980 | a topic that we're going to talk about in depth

01:54:20.140 | here on the podcast soon,

01:54:22.280 | some of those same drugs like Adderall,

01:54:25.060 | Vyvanse and things of that sort

01:54:27.180 | can also be used to treat bulimia and binge eating disorder.

01:54:31.620 | Why would that work?

01:54:32.620 | Well, now you are familiar with the prefrontal cortex.

01:54:35.260 | You probably know more about prefrontal cortex

01:54:36.740 | than you ever wanted to.

01:54:39.200 | Just from this episode, prefrontal cortex is involved

01:54:42.540 | in this analysis of duration, path and outcome.

01:54:45.420 | Duration, path and outcome is how we avoid impulsivity.

01:54:49.940 | It's how we think, okay, if this, then that,

01:54:52.060 | if that, then this,

01:54:52.900 | you can imagine how for the obsessive compulsive

01:54:54.840 | or for the anorexic, these are circuits that are overactive.

01:54:59.380 | For the bulimic, this is the circuit

01:55:02.480 | that's going to essentially be underactive

01:55:05.060 | and is under conditions where they think,

01:55:07.280 | oh, I shouldn't eat anything, I shouldn't eat anything.

01:55:09.300 | And then they just tear the refrigerator open

01:55:12.120 | and plow through that.

01:55:13.660 | And then at that point,

01:55:15.060 | they're plowing through the cupboards

01:55:16.180 | and then they're ordering food.

01:55:17.320 | And then they're feeling horrible about themselves.

01:55:19.380 | There do tend to be these cycles of binge and purge

01:55:22.860 | followed by feelings of real shame

01:55:25.980 | because they just can't control their behavior.

01:55:28.660 | And what is more embarrassing

01:55:29.960 | than not being able to control one's behavior

01:55:32.020 | as an adult or as a young adult.

01:55:34.620 | So really the polar opposite of what you see

01:55:36.860 | in anorexia.

01:55:38.580 | So this lack of impulsivity

01:55:40.800 | implies a lack of prefrontal control,

01:55:43.000 | what we call top-down control.

01:55:44.180 | Why do we call it top-down?

01:55:45.060 | Because the prefrontal cortex is suppressing the activity

01:55:48.060 | of deeper limbic and hypothalamic circuitry

01:55:51.940 | and things of that sort.

01:55:53.580 | Anytime you feel like you want to say something

01:55:56.660 | really offensive and you don't, that's top-down control.

01:56:01.660 | That's your prefrontal cortex.

01:56:03.120 | Anytime someone says something and you like,

01:56:06.060 | like grit your teeth

01:56:07.140 | 'cause you know you shouldn't say anything,

01:56:08.840 | gritting your teeth is top-down control, okay?

01:56:11.740 | When you explode or burst or say the wrong thing

01:56:15.020 | or say the thing that you shouldn't say

01:56:17.260 | or do the thing you shouldn't do,

01:56:18.580 | that's lack of prefrontal control.

01:56:20.260 | And indeed people who have frontotemporal dementia

01:56:22.640 | due to aging or head injuries see this a lot

01:56:25.260 | and people play sports that get a lot of frontal damage,

01:56:29.640 | they become more impulsive.

01:56:31.220 | So bulimics have an issue with impulsivity.

01:56:35.600 | And therefore drugs that can increase serotonin

01:56:39.540 | and sometimes these drugs that increase dopamine

01:56:42.380 | and adrenaline, also called epinephrine,

01:56:45.120 | will increase the tone, as we call it,

01:56:47.740 | the dopaminergic tone or the norepinephrine,

01:56:51.060 | it's called adrenergic,

01:56:52.220 | but norepinephrine levels in the brain

01:56:54.580 | allow for more top-down control.

01:56:56.260 | And that's also why they're used to treat ADHD

01:56:58.840 | and attention deficit disorder.

01:57:00.480 | They tend to create a hyperfocus.

01:57:03.540 | They tend to push the brain into,

01:57:05.620 | these drugs tend to create a hyperfocus

01:57:07.200 | and tend to push the brain

01:57:08.480 | and general mode of processing into one in which you think,

01:57:11.220 | if this, then that, if this, then that,

01:57:13.300 | so anticipating outcomes.

01:57:15.260 | And for that reason, drugs like Wellbutrin, buprenerone,

01:57:20.160 | which is an antidepressant,

01:57:21.260 | which mainly increases the amount of dopamine

01:57:23.960 | and norepinephrine and less so serotonin,

01:57:26.740 | that can also be effective

01:57:27.860 | for certain types of binge eating disorder

01:57:29.860 | is actually used to treat smoking

01:57:32.620 | for promoting smoking cessation and for depression,

01:57:37.180 | but also for certain forms of obesity

01:57:39.860 | related to binge eating disorder.

01:57:41.560 | And the data are pretty good

01:57:42.700 | and there are timed release forms of this

01:57:44.500 | and non-timed release forms.

01:57:45.620 | And I think you have to consult with a psychiatrist

01:57:49.220 | in order to get these prescribed

01:57:50.620 | because they are prescription drugs,

01:57:51.900 | but it's a very different constellation of neurochemicals

01:57:55.220 | and brain areas and approaches for bulimia.

01:57:59.200 | The treatment of binge eating disorder

01:58:01.540 | has been explored from a new standpoint recently,

01:58:05.260 | and that's the work of this now, sadly,

01:58:07.980 | former colleague of mine, Dr. Casey Halpern,

01:58:10.340 | who's at University of Pennsylvania

01:58:13.380 | that I mentioned earlier.

01:58:14.760 | They are using deep brain stimulation

01:58:17.420 | in order to treat binge eating disorder.

01:58:19.740 | Now, why deep brain stimulation?

01:58:21.660 | Well, work from Dr. Halpern and others while at Stanford

01:58:26.660 | showed that there are particular patterns of brain activity

01:58:31.300 | in both the prefrontal cortex,

01:58:33.300 | but also in an area of the brain

01:58:34.900 | called the nucleus accumbens,

01:58:36.580 | very important and very relevant area of the brain

01:58:40.260 | in this context.

01:58:41.120 | And in any discussion about motivated behaviors of any kind,

01:58:45.620 | feeding, sex, drug related behavior,

01:58:48.840 | people exercise compulsively,

01:58:51.260 | the nucleus accumbens is in a ongoing dialogue

01:58:54.640 | with the prefrontal cortex.

01:58:55.860 | And the nucleus accumbens has no mind of its own,

01:58:58.660 | but it's associated with dopamine release.

01:59:00.420 | It's part of this so-called reward pathway.

01:59:03.460 | And what Dr. Halpern and colleagues discovered

01:59:06.540 | is that there are particular patterns of activity

01:59:09.160 | that ripple through the brain

01:59:11.100 | through these prefrontal networks

01:59:12.940 | and through this nucleus accumbens area,

01:59:14.980 | those areas are connected, it's called delta oscillations,

01:59:18.980 | delta just being a particular frequency

01:59:21.300 | of electrical activity for you aficionados

01:59:23.620 | is one to four Hertz activity.

01:59:25.320 | But in any case, those delta oscillations

01:59:29.540 | in the nucleus accumbens are associated with food reward

01:59:33.360 | in both mice and humans.

01:59:35.060 | Somehow this reverberatory activity

01:59:38.280 | creates a perception in the individual

01:59:40.400 | that food is hyper rewarding.

01:59:42.440 | That's interesting and has allowed them to use

01:59:46.100 | a targeted deep brain stimulation approach

01:59:48.820 | to treat binge eating disorder.

01:59:50.740 | And this deep brain stimulation

01:59:53.140 | is appearing to be an effective treatment.

01:59:55.360 | There's still more studies that need to be done.

01:59:57.880 | Actually, if you think you have binge eating disorder,

02:00:01.640 | you can find the criteria for that

02:00:03.960 | and you could contact Dr. Halpern.

02:00:06.600 | As I mentioned, he's moving to University of Pennsylvania.

02:00:08.640 | They are recruiting patients for these studies all the time.

02:00:12.240 | The studies are fairly invasive.

02:00:13.600 | They involve a FDA approved approach

02:00:16.760 | of literally placing a wire down into an area of the brain

02:00:21.040 | that then allows the individual

02:00:24.300 | to stimulate a particular brain area

02:00:26.740 | to offset some of these activity patterns

02:00:30.060 | that lead to a elevated sense of reward

02:00:33.960 | from food and binge eating.

02:00:35.740 | And the data look really promising.

02:00:37.420 | Now I realize that's a very invasive approach.

02:00:39.680 | Not everybody is going to be willing

02:00:42.040 | to have this wire inserted into the brain,

02:00:44.500 | but for people that suffer from binge eating disorder,

02:00:47.080 | this is a great and very exciting potential treatment,

02:00:52.080 | because what I didn't tell you

02:00:53.900 | is that many people who have binge eating disorder are obese

02:00:57.140 | to the point where their health is greatly at risk.

02:00:59.800 | Now, obesity causes all sorts of shifts

02:01:03.760 | in the dialogue between the brain and body,

02:01:06.440 | some of which you'll recognize

02:01:07.960 | from earlier in the discussion.

02:01:09.920 | For instance, leptin signaling is disrupted.

02:01:13.580 | So the fat, there's lots of body fat,

02:01:16.160 | but even though that body fat

02:01:18.000 | is secreting this hormone leptin

02:01:19.400 | and that signal should shut down the desire to eat,

02:01:23.160 | the receptors to leptin in the brain are totally screwed up.

02:01:26.920 | And so the signal to eat is there,

02:01:29.060 | but the signal to stop eating is not there.

02:01:31.360 | So again, you have an accelerator and a brake,

02:01:33.060 | and it's like the accelerator is always pushed down.

02:01:35.660 | Some of these brain stimulation approaches

02:01:37.340 | seem to be able to bypass some of that.

02:01:40.020 | And of course, there are all the metabolic syndromes

02:01:42.020 | and the problems with having excess levels of body fat,

02:01:45.700 | things like insulin resistance, type two diabetes.

02:01:48.620 | I mean, as disturbing as is to hear,

02:01:52.640 | there are many individuals, actually,

02:01:53.780 | I know some who are so obese

02:01:57.560 | that they start getting bodily sores.

02:01:59.700 | They're not just bed sores,

02:02:00.660 | but they have skin sores that are very disruptive to them.

02:02:05.020 | They don't like having these sores.

02:02:06.800 | And in addition to that,

02:02:08.280 | they can get peripheral neuropathies

02:02:10.260 | because of some of these metabolic issues.

02:02:12.880 | They're not getting enough utilization

02:02:16.000 | of the nutrients in the tissue

02:02:17.840 | because the way that insulin is disrupted,

02:02:20.760 | insulin signaling, and they actually have to have

02:02:22.840 | certain portions of their limbs amputated,

02:02:24.700 | and yet they continue to overeat.

02:02:26.540 | So this is not an issue of self-control

02:02:29.280 | that can easily be dealt with

02:02:31.560 | simply by telling the person,

02:02:32.640 | look, you have to stop eating or you're going to die,

02:02:34.900 | or you're going to have your legs amputated.

02:02:36.900 | Like with anorexia,

02:02:38.280 | there's a distortion in the relationship to food,

02:02:41.800 | but the homeostatic and the reward aspects are disrupted.

02:02:45.820 | So unlike anorexia,

02:02:47.060 | where it seems to be a habit-based mechanism

02:02:50.140 | with bulimia and binge eating disorder,

02:02:53.160 | something deep within the neural circuitry

02:02:54.860 | is causing food to be hyper attractive

02:02:58.240 | and the break is off.

02:03:00.080 | So if you want to develop some empathy

02:03:02.140 | for what these people are dealing with, consider this.

02:03:04.720 | It's like driving a car.

02:03:06.440 | You get onto a grade, maybe a 10 or 15 degree grade,

02:03:10.600 | and you're heading down and you figure,

02:03:13.440 | well, you'll just pump the brakes a little bit,

02:03:15.260 | but there is no break, right?

02:03:16.760 | So you start going faster and faster and faster,

02:03:18.880 | and your only choice is to use the accelerator

02:03:20.740 | or just to coast through it.

02:03:21.680 | That's essentially what's happening to these neural circuits.

02:03:24.460 | So the work of Dr. Halpern and others,

02:03:26.400 | I think is really exciting.

02:03:28.140 | And even though it's highly invasive,

02:03:29.820 | I think it's going to lead to not just some relief

02:03:33.120 | for the patients that do get that deep brain stimulation,

02:03:35.560 | but also the identification of what sorts of receptors

02:03:38.360 | are present in those brain areas that could help.

02:03:41.480 | What that means is that once we understand

02:03:44.320 | which brain areas are involved in the disorder

02:03:46.520 | and we understand what receptors those brain areas express,

02:03:51.400 | then there can start to be additional interventions

02:03:54.080 | by way of non-invasive treatments,

02:03:56.840 | things like drug treatments.

02:03:58.800 | Do behavioral interventions work for bulimia?

02:04:01.360 | In some cases, yes,

02:04:02.980 | provided that those interventions are done early enough.

02:04:06.140 | Regardless, behavioral interventions

02:04:09.320 | coupled with drug-based interventions

02:04:11.040 | are always more effective than either one alone.

02:04:13.320 | Fortunately, there is a decent size kit of drugs

02:04:17.100 | that can help with bulimia.

02:04:18.100 | I mentioned some of them before,

02:04:19.300 | things like buprenterone, wellbutrin,

02:04:21.680 | some of the serotonergic drugs

02:04:23.440 | and some of the drugs used to treat impulsivity.

02:04:26.120 | So we have on the one hand anorexia,

02:04:29.840 | which seems to be a disruption in habit

02:04:31.660 | and a coupling of unhealthy habits,

02:04:35.120 | in this case, food restriction, to the reward pathway.

02:04:39.160 | And on the flip side,

02:04:40.360 | we have binge eating disorder and bulimia

02:04:42.800 | where a very unhealthy habit of gorging oneself with food,

02:04:46.160 | sometimes followed by purging,

02:04:48.080 | is not necessarily coupled to reward.

02:04:49.940 | They feel terrible when they do that, right?

02:04:52.000 | The anorexic feels great

02:04:53.200 | about restricting their food intake.

02:04:54.920 | They feel like they're winning some sort of game.

02:04:57.020 | The circuitry is flipped somehow that way.

02:04:59.640 | With bulimia, they feel horrible

02:05:03.200 | about the fact that they're binging.

02:05:04.640 | There's immense shame.

02:05:05.960 | They can't control themselves.

02:05:08.040 | The reward is set up before the behavior.

02:05:10.940 | The reward is set up in drawing them to food

02:05:15.020 | and in making food look like something

02:05:17.120 | that's incredibly appetizing and there's no impulse break.

02:05:21.420 | There's no way for them to stop that kind of behavior.

02:05:24.100 | So really kind of troubling thing to think about.

02:05:26.640 | In either case, I think for those of us

02:05:28.960 | that know anorexics or have observed anorexia,

02:05:31.760 | it's so hard to see somebody starve themselves

02:05:34.100 | to near death or to death.

02:05:35.400 | What more could be disturbing?

02:05:37.760 | Well, equally disturbing is somebody who has an abundance

02:05:41.960 | of food and is gorging themselves

02:05:43.520 | and then feels terrible about it.

02:05:45.100 | So these are heavy topics.

02:05:48.800 | These are topics that frankly,

02:05:51.520 | no one really wants to talk about

02:05:53.040 | unless they know someone who's suffering from them

02:05:55.000 | or they themselves suffer from them.

02:05:56.940 | What I've tried to do today is try and give you a window

02:05:59.720 | into what really underlies these things

02:06:02.700 | that we call eating disorders.

02:06:05.080 | I hope I've done that at the level of biology,

02:06:07.460 | neurocircuitry, mechanism, endocrinology,

02:06:09.620 | and some of the psychology.

02:06:11.120 | As with any episode of this podcast,

02:06:14.100 | but especially in this month where we're talking

02:06:16.100 | about mental health issues and mental health disorders,

02:06:19.320 | behavioral disorders, there's no way

02:06:22.040 | that I can exhaustively cover all the different forms

02:06:24.600 | of treatment.

02:06:25.440 | You have the modally approach.

02:06:26.440 | You've got all these different approaches to depression

02:06:29.000 | and to anorexia, et cetera.

02:06:31.580 | What I've tried to do is give you a framework.

02:06:33.860 | And in doing that, I've tried to give you a framework

02:06:36.020 | of understanding that also applies to this question

02:06:39.080 | that's I think equally important

02:06:41.600 | and goes alongside the treatment of eating disorders

02:06:43.780 | is what in the world is healthy eating?

02:06:46.220 | What in the world is a healthy relationship to food?

02:06:48.640 | I like to think that I have a healthy relationship to food.

02:06:51.000 | I know the foods I like, I enjoy them.

02:06:53.220 | There are 10 or 15 foods in particular

02:06:55.000 | that I like very much.

02:06:56.080 | I've mentioned a few of them on the podcast before

02:06:58.200 | and was sort of amused, surprised, and perplexed

02:07:03.800 | as to why, for instance, I do enjoy eating butter,

02:07:06.660 | not in huge amounts, but I do like butter.

02:07:09.300 | So that seemed to be pretty triggering for folks out there.

02:07:12.440 | A small selection of people decided

02:07:14.780 | that the ingestion of butter was a health concern.

02:07:17.460 | Look, to me, ingesting butter in small quantities

02:07:22.460 | is something that I'm comfortable with

02:07:23.920 | and my blood lipid profiles feel good.

02:07:26.260 | They look good to me.

02:07:27.720 | For other people, that might not be the case.

02:07:29.940 | For some people, the idea of eating an animal-based food

02:07:33.840 | is probably so repulsive

02:07:35.940 | that it actually can make them feel physically sick.

02:07:39.360 | And I think that we should be aware

02:07:41.240 | that that kind of mental phenotype exists.

02:07:43.820 | I'm not calling it a pathology.

02:07:45.320 | For other people like myself,

02:07:46.660 | things like butter and meat feel healthy.

02:07:48.840 | Now, what quantities?

02:07:49.960 | Well, I enjoy eating very much.

02:07:51.900 | I'm not shy about this.

02:07:52.860 | I've talked about it in the podcast before.

02:07:54.920 | I enjoy eating.

02:07:56.480 | Some people have a very complicated relationship to food.

02:08:00.080 | They don't think of it as nourishment.

02:08:01.720 | They don't enjoy it socially.

02:08:03.700 | It's a stressful thing for them

02:08:05.180 | based on their personal history

02:08:06.940 | or maybe just general anxiety around food.

02:08:10.740 | And I hope that in sharing this information

02:08:13.020 | about the fact that anytime we approach food,

02:08:16.540 | these neurons in the arcuate area of our hypothalamus

02:08:20.240 | actually increase our levels of anxiety.

02:08:22.260 | This is related to that point that Dr. Halpern made,

02:08:24.880 | which was that from an evolutionary standpoint,

02:08:27.800 | it is advantageous to ingest as much food

02:08:30.140 | as often as possible, as quickly as possible.

02:08:32.520 | We now know that to not be healthy in this age of abundance

02:08:35.260 | where calories are essentially everywhere.

02:08:39.540 | And yet a lot of people feel anxious

02:08:44.540 | in anticipation of a meal.

02:08:45.840 | What could be useful to them?

02:08:47.340 | Well, whether or not they have an eating disorder or not,

02:08:50.240 | it's very clear that developing methods to calm oneself

02:08:53.940 | in the presence of any anxiety

02:08:55.760 | or fear inducing stimulus can be beneficial.

02:08:57.940 | I've talked about some of these

02:08:58.980 | in episodes related to stress,

02:09:00.820 | things like the physiological side,

02:09:02.220 | two inhales through the nose and a long exhale.

02:09:04.700 | Things like mindfulness meditation certainly can help.

02:09:07.180 | There are data, a lot of studies out there

02:09:08.900 | showing that meditation practice can help people deal with

02:09:11.860 | eating related anxiety and disorders.

02:09:14.460 | I think as a general rule,

02:09:15.580 | trying to avoid approaching a meal

02:09:18.020 | or sitting down to eat in an anxious state

02:09:21.100 | is probably a good idea, but let's be realistic.

02:09:22.860 | How often can we do that?

02:09:23.960 | I think most of us are going to have circumstances

02:09:27.060 | where we're rushing around trying to just eat

02:09:29.380 | before we head out or get to a meal.

02:09:31.180 | And then we sit down and we find ourselves eating.

02:09:33.560 | This is one of the first times in human evolution

02:09:35.940 | where we mostly eat out of a desire to consume food,

02:09:40.940 | not out of a need for food.

02:09:43.100 | Most everybody could go a fairly long period of time

02:09:46.860 | just ingesting water and electrolytes

02:09:49.260 | and not that I'm suggesting people do that,

02:09:50.800 | but let's face it.

02:09:52.180 | We largely eat nowadays because of a desire to eat,

02:09:55.180 | not a need to eat.

02:09:56.700 | And yet we need to eat on a fairly regular basis.

02:09:59.780 | And so no topic is more complicated and nuanced

02:10:04.700 | than food and nutrition.

02:10:06.540 | And in particular, as it relates to eating disorder.

02:10:08.620 | So the major takeaways today are,

02:10:11.980 | we should all be asking the question,

02:10:13.140 | what is healthy eating for us?

02:10:15.220 | How do we develop a relationship to food

02:10:17.580 | that we can enjoy food,

02:10:19.420 | hopefully both socially and on our own,

02:10:21.780 | but that we are not neurotic and compulsive about it.

02:10:24.860 | For those of you that intermittent fast,

02:10:26.500 | this also applies, right?

02:10:28.180 | What, you know, God forbid,

02:10:29.500 | if you eat 30 minutes before your eating window starts,

02:10:32.060 | what does that mean?

02:10:32.900 | If it means something catastrophic,

02:10:34.860 | do you have an eating disorder?

02:10:35.980 | I don't know, maybe you have an anxiety disorder.

02:10:38.660 | That's for you to explore.

02:10:40.580 | If you don't manage to eat five meals a day

02:10:44.020 | and that's your obsession,

02:10:45.060 | well then, you know, the same thing applies.

02:10:47.820 | These are questions that we can all ask ourselves.

02:10:50.100 | Today we focus on the extremes of food related behaviors

02:10:54.540 | that really qualify as genuine disorders.

02:10:57.940 | They are in the psychiatric manuals and they are diagnosable

02:11:01.900 | and they are serious health concerns.

02:11:04.940 | They're not just mentally troubling and concerning

02:11:07.420 | for the people suffering from them

02:11:08.680 | and the people around them,

02:11:09.740 | but they are genuine health concerns.

02:11:11.980 | Just want to reiterate that anorexia nervosa

02:11:15.000 | is the most deadly psychiatric disorder by a huge margin.

02:11:19.740 | And if you look statistically at the number of people

02:11:22.200 | with eating disorders and that die of eating disorders,

02:11:25.640 | it's not far off from the number of people

02:11:27.680 | that die from automobile accidents.

02:11:29.940 | I know that that sounds like a ridiculous number,

02:11:31.940 | but you can look this up.

02:11:32.780 | This is particularly true in certain countries.

02:11:35.480 | Why that is, we don't know.

02:11:37.200 | But again, this is not a new phenomenon.

02:11:40.020 | This is not just related to body image issues

02:11:44.440 | that are created through social media and media.

02:11:46.920 | And as a final point on that,

02:11:48.760 | many of you are probably asking,

02:11:51.040 | what about plastic surgery?

02:11:53.540 | What about all the steps that people are going to through,

02:11:56.700 | excuse me, to preen themselves and change themselves?

02:11:59.460 | Are people addicted to plastic surgery?

02:12:01.780 | Is that a form of body dysmorphia?

02:12:03.980 | And indeed it is.

02:12:04.820 | And so we will do an episode on exercise related

02:12:08.440 | and plastic surgery related body dysmorphia.

02:12:11.900 | I think there is very little question

02:12:14.360 | that those types of disorders are clearly related

02:12:20.000 | to what we're observing in social media and in media,

02:12:23.620 | that this shift of, for instance, action heroes,

02:12:27.060 | if you look at action heroes in the '80s,

02:12:29.160 | there were very few men that were very large.

02:12:31.520 | You had your Stallone's and your Schwarzenegger's

02:12:34.000 | and a few others.

02:12:35.200 | But the men in movies tended to be, if they were muscular,

02:12:39.040 | they were far more svelte than they are now.

02:12:41.680 | There's this kind of,

02:12:42.520 | there's literally a hypertrophy of the imagery.

02:12:45.360 | And likewise, there's been hypertrophy

02:12:48.480 | of the female body shape as it's portrayed in the media.

02:12:51.480 | There are body dysmorpheas that are related

02:12:55.260 | to those types of things.

02:12:56.560 | And that relate to things like plastic surgery,

02:12:58.840 | steroid abuse, diet drug abuse, and so on.

02:13:03.500 | Definitely important to think about and consider

02:13:06.560 | and definitely deserving of its own episode.

02:13:08.840 | You've learned a lot of neuroscience today.

02:13:12.080 | I hope that was useful in thinking about these disorders

02:13:14.720 | and in thinking about other aspects of feeding

02:13:17.400 | and motivated behaviors.

02:13:18.860 | I would love for you to take away this model

02:13:21.680 | that was handed off to me that I think is so powerful

02:13:24.040 | for thinking about all sorts of things, not just eating,

02:13:26.520 | but all kinds of behaviors and perceptions

02:13:28.240 | that you have one box for what you think,

02:13:31.520 | one box for what you do.

02:13:33.200 | And what is intervening between those?

02:13:35.340 | Why is it that you can know better and not do better?

02:13:38.280 | Well, it's because you also have to cope

02:13:40.700 | with the subconscious homeostatic processes

02:13:43.620 | and reward processes.

02:13:45.040 | And those oftentimes can be disrupted in ways

02:13:48.500 | that we find ourselves doing things that are not good

02:13:51.880 | for us or not good for other people.

02:13:53.260 | But fortunately there is this great gift,

02:13:56.180 | which is that knowledge of knowledge can allow you

02:13:58.840 | to do better without question.

02:14:01.540 | And that knowledge of knowledge allowing you to do better

02:14:05.520 | over time leads to this incredible phenomenon

02:14:08.000 | called neuroplasticity, which essentially is translated

02:14:10.740 | into doing better over time, even if difficult,

02:14:14.340 | eventually makes doing better reflexive.

02:14:16.900 | If you're enjoying this podcast and learning from it,

02:14:19.560 | please subscribe to our YouTube channel.

02:14:21.380 | That's Huberman Lab on YouTube.

02:14:23.400 | And there, you can also leave us comments and feedback

02:14:26.200 | and suggestions for future topics and future guests

02:14:29.820 | for the Huberman Lab podcast.

02:14:31.780 | As well, we hope that you will subscribe

02:14:33.600 | on both Apple and Spotify.

02:14:35.220 | And on Apple, you have the opportunity to leave us

02:14:37.640 | up to a five-star review

02:14:39.360 | and to give us feedback there as well.

02:14:41.840 | Please also check out the sponsors mentioned

02:14:43.520 | at the beginning of the podcast.

02:14:44.780 | That's a terrific way to support the podcast.

02:14:47.020 | And if you'd like to support research on stress,

02:14:49.620 | human performance, sleep, and so forth,

02:14:52.220 | you can go to Hubermanlab.stanford.edu.

02:14:55.500 | And there, there's a tab that you can click

02:14:57.820 | if you'd like to make a tax-deductible donation

02:15:00.880 | to the laboratory to explore the sorts of things

02:15:03.060 | that relate to neural circuits, stress,

02:15:04.660 | sleep, and human performance.

02:15:06.920 | Not today, but oftentimes on this podcast,

02:15:09.340 | we discuss various compounds and supplements

02:15:11.500 | that people could possibly take

02:15:13.880 | in order to help deal with anxiety, improve gut microbiome,

02:15:18.440 | improve their sleep, et cetera.

02:15:20.420 | We didn't discuss those today,

02:15:21.500 | but for those of you interested in those compounds,

02:15:23.280 | if you want to see the ones that I take,

02:15:25.160 | you can go to Thorne.

02:15:26.980 | That's T-H-O-R-N-E.com/u/huberman.

02:15:31.980 | So it's Thorne.com/u/huberman.

02:15:35.900 | See all the supplements that I take.

02:15:37.300 | You get 20% off any of those supplements.

02:15:39.580 | And if you enter the Thorne site through that portal,

02:15:41.580 | you can get 20% off any of the supplements that Thorne makes.

02:15:45.060 | We partnered with Thorne

02:15:46.100 | because they have the highest levels of stringency

02:15:48.820 | with respect to the quality of ingredients,

02:15:51.280 | the precision of the amounts of those ingredients.

02:15:53.660 | And while supplements are certainly not required

02:15:55.740 | or necessary for anything, really,

02:15:58.300 | you can always use behavioral tools.

02:15:59.620 | Many people benefit from taking supplements of various kinds.

02:16:02.160 | And we do believe that getting supplements

02:16:03.960 | of the very highest quality is going to be important

02:16:06.100 | if that's the decision for you.

02:16:08.460 | And last but not least,

02:16:10.060 | I want to thank you for your time and attention

02:16:12.460 | and thank you for your interest in science.

02:16:14.380 | [upbeat music]

02:16:16.960 | (upbeat music)

Healthy Eating & Eating Disorders - Anorexia, Bulimia, Binging | Huberman Lab Podcast #36

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